Empire Blue Cross Claim Form – Fill Out and Use This PDF

The Empire Blue Cross Claim form is a crucial document for members who have received services from a provider outside of the Empire network, facilitating the reimbursement of medical expenses. It requires detailed information about the patient, the insured, and the medical services rendered. For a smooth claims process, ensure all sections are completed accurately before submitting the form by clicking the button below.

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Empire Blue Cross Claim Form PDF Details

Filing a health insurance claim with Empire Blue Cross requires thorough attention to detail, especially when using the Empire Blue Cross Claim form. This form serves as a crucial document for individuals seeking reimbursement or direct payment for healthcare services from providers outside the Empire Blue Cross network. It encapsulates various sections, including patient and insured information, physician or supplier details, and comprehensive instructions to ensure accurate and complete submission. Whether the healthcare services arise from routine visits, emergency treatment, or are related to employment, auto accidents, or another incident, every aspect must be meticulously documented. The form uniquely identifies each claim through details such as Medicare, Medicaid, or other insurance information, alongside personal identifiers like the insured's ID and patient's relationship to the insured. Moreover, it factors in the complexities of healthcare services, addressing situations involving other insured policies, employment-related conditions, and specifics about the healthcare provider. To facilitate the processing of claims, it mandates the attachment of original itemized bills or the completion of sections dedicated to the services provided. Empire Blue Cross emphasizes the need for the patient’s or their legal guardian's authorization, both for the release of pertinent medical information and for the understanding of the financial aspects, such as charges, payments, and balances due. Additionally, it stipulates clear guidelines aimed at preventing fraudulent claims, underscoring the legal implications of submitting false information. Through this form, Empire Blue Cross outlines a structured pathway for members to claim their benefits, ensuring transparency and efficiency in handling healthcare expenses.

Question	Answer
Form Name	Empire Blue Cross Claim Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	phy tww blue template, empire hcfa blue shield, tww claim blue cross, empire bcbs claim form

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APPROVED OMB-0938-0008

		PO BOX 5072
		PO BOX 5072
		MIDDLETOWN, NY 10940-9072
		ATTN: CLAIM SET-UP
		FOR CUSTOMER SERVICE: 1-800-409-1620	Note: Important filing instructions
		FOR CUSTOMER SERVICE: 1-800-409-1620

PICA	HEALTH INSURANCE CLAIM FORM		on next page.

CARRIER

PICA

1. MEDICARE

MEDICAID

CHAMPUS

CHAMPVA

GROUP

FECA

OTHER

1a. INSURED’S ID NUMBER

(FOR PROGRAM IN ITEM 1)

HEALTH PLAN

BLK LUNG

TWWAOL

(Medicare #)

(Medicaid #)

(Sponsor’s SSN)

(VA File #)

X (SSN or ID)

(SSN)

(ID)

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

3. PATIENT’S BIRTH DATE

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

SEX

5. PATIENT’S ADDRESS (No. and Street)

6. PATIENT RELATIONSHIP TO INSURED

7. INSURED’S ADDRESS (No. and Street)

Self

Spouse

Child

Other

CITY

STATE

8. PATIENT STATUS

CITY

STATE

Single

Married

Other

ZIP CODE

TELEPHONE (Include Area Code)

ZIP CODE

TELEPHONE (Include Area Code)

Employed

Full-Time

Part-Time

Student

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP OR FECA NUMBER

296541

a. OTHER INSURED’S POLICY OR GROUP NUMBER

a. EMPLOYMENT? (Current or Previous)

a. INSURED’S DATE OF BIRTH

SEX

YES

b. OTHER INSURED’S DATE OF BIRTH

b. AUTO ACCIDENT?

PLACE (State)

b. EMPLOYER’S NAME OR SCHOOL NAME

SEX

YES

AOLTIME WARNER, INC.

c. EMPLOYER’S NAME OR SCHOOL NAME

c. OTHER ACCIDENT?

c. INSURANCE PLAN NAME OR PROGRAM NAME

YES

PPO PLAN

d. INSURANCE PLAN NAME OR PROGRAM NAME

d. RESERVED FOR LOCAL USE

d. IS THERE ANOTHER NAME OR BENEFIT PLAN?

YES

If YES, return to and complete item 9a–d.

READ BACK OF FORM BEFORE COMPLETING THIS SECTION.

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment

12. I AUTHORIZE THE RELEASE OF INFORMATION AS DESCRIBED ON THE REVERSE SIDE OF THIS CLAIM FORM.

of medical benefits to the undersigned physician or supplier for services

described below.

NOT APPLICABLE

SIGNED _____________________________________________________________

DATE ________________________________

SIGNED ___________________________________________________________

14. DATE OF CURRENT:

ILLNESS (First symptom) OR

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

INJURY (Accident) OR

PREGNANCY (LMP)

GIVE FIRST DATE

FROM

17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE

17a. ID NUMBER OF REFERRING PHYSICIAN

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

FROM

19. RESERVED FOR LOCAL USE

20. OUTSIDE LAB?

$ CHARGES

YES

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (RELATE ITEMS 1, 2, 3 OR 4 TO ITEM 24E BY LINE)

22. MEDICAID RESUBMISSION

ORIGINAL REF. NO.

CODE

23. PRIOR AUTHORIZATION NUMBER

24.

DATE(S) OF SERVICE

PLACE

TYPE

PROCEDURES, SERVICES OR SUPPLIES

DAYS

EPSDT

FROM

(EXPLAIN UNUSUAL CIRCUMSTANCES)

DIAGNOSIS

$ CHARGES

FAMILY

EMG

COB

RESERVED FOR

SERVICE

CPT/HCPCS

MODIFIER

CODE

UNITS

PLAN

LOCAL USE

25. FEDERAL TAX ID NUMBER

SSN

EIN

26. PATIENT’S ACCOUNT NO.

27. ACCEPT ASSIGNMENT?

28. TOTAL CHARGE

29. AMOUNT PAID

30. BALANCE DUE

YES

31. SIGNATURE OF PHYSICIAN OR SUPPLIER,

32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE

33. PHYSICIANS, SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE

INCLUDING DEGREES OR CREDENTIALS

RENDERED (If other than home or office)

AND PHONE NUMBER

I CERTIFY THAT THE CARE, SERVICES AND SUPPLIES

ENTERED ON THIS FORM HAVE BEEN RENDERED TO THE

PATIENT, AND THAT I AM ENTITLED TO REIMBURSEMENT OF

THE CHARGES INDICATED.

SIGNED

DATE

PIN#

GRP#

(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)

PLEASE PRINT OR TYPE

FORM HCFA-1500 (12-90)

Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

FORM OWCP-1500

PHY 0744E-TWW 11/06

PATIENT AND INSURED INFORMATION

PHYSICIAN SUPPLIER INFORMATION

Empire Blue Cross Claim Form – Fill Out and Use This PDF

Empire Blue Cross Claim Form PDF Details

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