Bluecross Blueshield Claim Form PDF Details

Navigating through the process of filing a health insurance claim can be daunting, yet the BlueCross BlueShield Claim Form is designed to streamline this experience, ensuring members can efficiently submit their requests for coverage. Located at P.O. Box 660044, Dallas, Texas, 75266-0044, this form requires detailed information to be filled out about the insured or subscriber, including name, identification number, group number, and specifics regarding employment status. It's crucial for claimants to provide accurate patient information, such as full name, relationship to the insured, and personal details like date of birth and sex, along with specifying the kind of treatment received, whether it’s for an injury, illness, pregnancy, or preventive care. The form also inquires about work-related injuries, other insurance coverage, and Medicare details to ensure comprehensive processing. Understanding and completing each section accurately is vital for the swift adjudication of claims. To avoid delays, itemized bills for the services and supplies must accompany the claim form. For Medicare enrollees, including a copy of the Medicare Explanation of Benefits with the itemized statements is necessary unless there's primary group coverage due to active employment. This protocol underscores the importance of transparency and thoroughness in the claims process, facilitating a smoother interaction between the insured, healthcare providers, and BlueCross BlueShield of Texas.

QuestionAnswer
Form NameBluecross Blueshield Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesblueshield claim form to, blue cross blue shield fep claim forms, claim form for blue cross blue shield, bcbs claim form online

Form Preview Example

 

P.O. Box 660044

 

Dallas, Texas 75266-0044

 

Each item on this form needs to be completed.

Please Print or Type

Instructions for completion are listed on the reverse side.

Claim Form

to Pay

Insured/Subscriber

 

Insured/Subscriber Name (Last, First, Middle Initial)

 

 

 

 

 

 

1

 

2

Group Number

Insured/Subscriber Identification Number (from ID card)

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address

 

 

 

Patient's Full Name (Last, First, Middle)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City & State

 

 

Zip Code

Patient's Sex

Patient's Date of Birth

Month Day

Year

 

 

 

 

 

 

■ Male ■ Female

 

_____ /_______ /____

 

 

 

 

 

 

 

 

 

 

 

Insured Employed?

 

Date of Retirement

Patient's Relationship to Insured

 

 

 

■ Yes ■ No

■ Retired

Month Date

Year

1. ■ Self 2. ■ Spouse

3. ■ Child 4.■ Other (explain) ____________________

 

/

/

 

 

 

 

 

 

 

 

 

3

Type of treatment received:

Check only one type and attach itemized statements. Please use a separate claim form for each different type of treatment.

*Please note: Preventive care includes immunizations, routine well baby care, routine physical examinations, vision and hearing exams.

 

Month Day Year

■ Injury — Date of Accident:

______ /______ /______

■ Illness — Date of First Symptom:

______ /______ /______

■ Pregnancy — Date of Conception:

______ /______ /______

■ Preventive — Date of Service:

______ /______ /______

4

Describe: Diagnosis, Symptoms of Illness or Injury or explain Preventive or Routine care received.

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

5

Was Illness or Injury work connected? ■ Yes ■ No

Name and Address of Employer

 

__________________________________________________

6

If Injury, was motor vehicle involved?

■ Yes ■ No

__________________________________________________

7

Is patient covered under any other Health Benefits Plan (besides Medicaid, Medicare or CHAMPUS)? ■ Yes ■ No

Insuring Co.____________________________________

Policy # ______________________

Month Day Year

Address_______________________________________

Effective Date of Coverage

______/______/______

Employer______________________________________

Sex ■ Male ■ Female

Birthdate

______/______/______

 

(Insured)

(Insured)

 

Insured________________________________________ Relationship to Patient_________________________________

If the other coverage is primary, attach the other insurance company's Explanation of Benefits

8

Medicare — Is the Patient:

 

 

Month

Day Year

a) Entitled to Benefits Under Medicare Hospital Insurance (Part A)?

■ Yes ■ No

Effective ______/______/______

b) Entitled to Benefits Under Medicare Medical Insurance (Part B)?

■ Yes ■ No

Effective

______/______/______

c) Entitled to Benefits Under Medicare due to a disability?

■ Yes ■ No

Effective

______/______/______

Patient's Medicare Identification No. (From Medicare ID Card)____________________________

9I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization is hereby given to any Hospital, Physician, Dentist, Provider, Insurance Carrier or other entity to give Blue Cross and Blue Shield of Texas, upon request, any medical information which the Plans in their judgment deem necessary to the adjudication of this claim. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

_____________________________________

_________________

__________________________

Signature of Insured

Date

Daytime Telephone Number

Itemized Bill(s) for Covered Services and Supplies must be attached

(See Instructions on Reverse Side)

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

1081.000-901

Instructions

Important: Do Not file this form if your Provider of Service is submitting these charges to Blue Cross and Blue Shield of Texas.

Please complete every item on claim form.

1

Insured's/Subscriber's Name, Address

Please show the insured's/subscriber's name exactly as it appears on the Blue Cross and Blue

and Employment Status

Shield of Texas identification card and specify the current address including the ZIP code.

 

Check appropriate box indicating the insured's /subscriber's employment status. If retired, give

 

date of retirement.

2

Patient Information

Make sure the group number and identification number are exactly as shown on the insured's

 

identification card. List patient's full name; no nicknames or initials please. Check the appro-

 

priate blocks for the patient's sex and relationship to the insured. Ensure the patient's correct

 

date of birth is shown.

3

Type of Treatment

Check only one treatment type (injury, illness, pregnancy or preventive care) and specify date

Received

of injury, date of first symptom, date of conception or date preventive care was received. You

 

may attach multiple itemized statements if they are for one type of treatment (example: illness

 

only, preventive care only).

4

5

6

7

8

9

Diagnosis or Symptoms

Give diagnosis or a brief description of symptoms. If preventive care services were received,

of Illness or Injury

state the type of care (routine physical, hearing exam, vision exam or immunization diagnosis,

 

etc.).

If Illness or Injury is in any

Check appropriate box and enter name and address of employer.

way work related

 

If Motor Vehicle Injury

Check appropriate box.

Other Insurance

Please check appropriate box. If “yes,” complete the required information.

Medicare Information

Please check appropriate box concerning Medicare eligibility. If “yes,” show effective date and

 

give Medicare identification number.

 

Medicare Enrollees should include a copy(s) of the Medicare Explanation of Benefits Form(s)

 

(EOB) with their itemized statements unless patient is actively employed and requires group

 

coverage to pay primary.

Insured's Signature, Date and Daytime

Please sign and date this form and attach your physician's itemized letterhead statement(s).

Telephone Number

The itemized statement)s) should contain all the information shown in the following example:

Itemized Bills Cannot Be Returned

Name of the patient receiving the

Services or supplies

Date each service or supply was provided

NOTE: Bills for Private Duty Nursing Service must show the professional status of the nurse (R.N. — Registered Nurse, L.V.N. — Licensed Vocational Nurse), the nurse’s license number, and must be accompanied by a statement from your physician indi- cating medical necessity and daily nurse’s progress notes.

Example of Itemized Bill

Dayton Penridge, M.D.

 

101 Fourth Street

 

Healthville, U.S.A.

 

For Professional Services Rendered To:

 

Virginia E. Warowes

Diagnosis: Arthritis

3/1/87 Office Care

$XXX

Examination

Cortisone Injection

XXX

3/2/87 Examination at Home

XXX

3/6/87 Physical Therapy

XXX

Description of the

Please cross out those charges which were

services or supplies

included on a previous claim.

provided

 

Name of the person or organization providing the services or supplies.

If you are submitting itemized bills for a variety of services please use a separate claim form for each different type of treatment (one for illness, another for an injury, etc.).

Charge for each service or supply

FOR OTHER THAN PRESCRIPTION DRUG CARD HOLDERS: Bills for Prescription Drugs must show the name of each drug, the prescription number, the quantity dispensed, the date of purchase, and the amount charged for each drug, If drug is generic then the pharmacist must also indicate on itemized bill.

This completed form, together with the itemized bills should be submitted to:

Blue Cross and Blue Shield of Texas

P.O. Box 660044

Dallas, Texas 75266-0044

Additional copies of this form may be obtained from your Employer, our nearest

Blue Cross and Blue Shield Area Office, or the above address.

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