INSTRUCTIONS FOR COMPLETION OF THE HEALTH BENEFITS CLAIM FORM
We at Blue Cross and Blue Shield of Georgia, Inc. value your membership. The following tips are
offered to ensure accurate and timely processing of your claim. If for any reason you should have
questions about this form, your claims or benefits, please call our Customer Service department. The
telephone number is listed at the bottom of this page.
I. Your contract number and group number are shown on your Membership card. Please copy the
numbers accurately. Please indicate the number of items you are attaching in the block provided.
II. The patient is the person who received the health care services or supplies. Please be sure the
patient’s name is included on every statement you file, along with the month, day and year of each
service provided. FILE SEPARATE CLAIM FORMS FOR EACH PATIENT.
Indicate in the additional blocks provided, the patient’s sex and relationship to the Employee and the
patient’s date of birth.
III. Please furnish the Employee’s name, current address and zip code. Please indicate if the address
given is a change from the previous address on record.
IV. If the patient is covered by another group health insurance program or MEDICARE, check “YES” and
furnish the name if the Policyholder, the policy number, the insurance company’s name and address, the
policyholder’s employer and the insurance group. If you are covered by Medicare, please enter your
Medicare number and state whether or not you have both Part A and Part B Medicare. If you do not
have other coverage, please check “NO”.
If you are covered by another health insurance company or Medicare, you must furnish your Explanation
of Benefits or Explanation of Medicare Benefits for the services you are filing on this claim. If you furnish
this at the time you file your claim, this will eliminate a delay in the processing of your claim.
V. Please DESCRIBE THE ILLNESS OR INJURY for which treatment was necessary. In the case of
multiple illnesses please indicate the illness of EACH itemization you are attaching. If the treatment was
for an injury, you must provide the date of the injury and how the injury occurred. If this information is not
included, your claim could be delayed in an effort to obtain the information.
VI. The patient (or authorized person) should sign and date the form.
OTHER TIPS FOR FILING A CLAIM
1. Make sure all statements are itemized and include a charge and a description of each service
rendered. If the statement reads “lab”, we must have the description of the procedure; if an x-ray, we
must have the description of the x-ray. You should contact your physician’s office for this information.
STATEMENTS STATING “BALANCE DUE” ARE NOT ACCEPTABLE; you must obtain an itemized
statement which is signed by your physician. The PHYSICIAN’S NAME must be on all statements. If
multiple physicians are listed, indicate which physician performed the services.
2. Hospital charges must be filed separately.
3. If you are filing charges from an in-network physician, the payment will be sent directly to the physician
since the agreement requires the physician to file claims for you. The participating physician has also
agreed to accept payment based on the usual, customary and reasonable (UCR) fee allowed before
benefit determination is made. You should not be balance billed for charges exceeding the UCR for
services rendered when the physician is participating.
4. Please make duplicate copies of all claims for your records.
IF YOU NEED INFORMATION ABOUT COMPLETING THIS FORM OR CLAIMS ASSISTANCE IN
GENERAL. PLEASE FEEL FREE TO CALL THE UNIVERSITY SYSTEM OF GEORGIA DIDICATED
CUSTOMER SERVICE DEPATMENT AT:
1-800-424-8950
