Form 11318 PDF Details

In the complex world of healthcare benefits and insurance claims, forms like the 11318 form serve as critical tools for individuals navigating their health plan benefits under the South Carolina Public Employee Benefit Authority (PEBA). This particular form is designed for insured individuals seeking reimbursement or payment for healthcare services rendered. It requires thorough documentation, including itemized bills that detail diagnoses, service dates, procedure codes, and provider information, ensuring that claims are processed accurately and efficiently. The form diligently gathers patient information, including their relationship to the insured, the nature of their illness or injury, and covers several contingencies, such as treatments resulting from accidents, Medicare coverage specifics, and other health benefit plans, demonstrating a comprehensive approach to claim filing. The requirement for the insured’s signature certifies the correctness of the information provided and authorizes the release of medical records necessary for claim processing. Completing this form accurately is a step toward securing proper payment for healthcare services, highlighting the intersection of healthcare delivery and insurance processes. This underscores the importance of understanding one's health benefits and the procedural nuances of claim submission in ensuring that individuals receive the healthcare benefits to which they are entitled.

QuestionAnswer
Form NameForm 11318
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesshp_claim state health plan comprehensive benefits claim form

Form Preview Example

state health plan benefits claim form

South Carolina Public Employee Benefit Authority (PEBA)

You must attach copies of itemized bills (including diagnoses, date(s) service(s) received, procedure codes,

provider name, and provider identification number(s)) to receive proper payment for your claim.

1

Insured’s Name

 

 

 

 

 

 

 

 

 

 

I.D.#

Zcs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

Patient’s Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle Initial

 

Last

 

 

 

First

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The patient is:

 

 

Female

 

 

 

 

 

 

 

 

 

 

 

3

 

☐

☐

Male

 

 

 

 

 

 

 

 

 

The patient is the:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐

Insured

☐

Insured’s Spouse

 

 

 

☐

Insured’s Child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

Patient’s Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insured’s

5Mailing Address

 

 

 

 

 

Street

 

 

 

City

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 Was the treatment required as a result of accidental injury?

 

 

 

If yes, give date of accident

 

 

☐

Yes

☐

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

medicare information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the patient covered by Medicare?

☐

Yes

☐

No

If yes, give date of Medicare No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, does the patient have Medicare Part A (Hospital Benefits)?

 

 

 

 

 

 

 

 

 

 

Yes

 

Date coverage became effective _____/ ____/ ____

 

 

 

 

 

 

 

☐

☐

No

 

 

 

 

 

 

7If yes, does the patient have Medicare Part B (Medical Surgical Benefits)?

☐

Yes

☐

No

Date coverage became effective ____/ ____/ ____

 

 

 

 

 

 

 

 

 

 

 

 

 

Is patient entitled to Medicare because of ESRD?

☐

Yes

 

☐

No

Is patient actively working?

 

 

 

Yes

 

 

No

 

 

☐

☐

Is the patient disabled?

 

 

 

 

 

 

 

 

 

☐

Yes

☐

No

Is the patient retired?

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

☐

☐

No

If yes, give the date of retirement

____/ ____/ ____

other group insurance coverage

Is the patient covered under any other health benefit plan?

☐

Yes

☐

No

if yes, you must complete this section so your claims can be processed.

A. Name of other insurance company

8

Address of other insurance company

B.Name of insured under this policy (policyholder) Relationship to patient

Insured’s date of birth

C.Effective date of other insurance policy Policy number of other insurance policy

Always attach your Explanation of Beneits or explanation of payment from your other plan.

 

 

certification of member

 

 

 

9

I certify that the above information is correct and that the foregoing expenses were incurred for the above-named patient.

I authorize any physician, nurse, hospital or other provider or supplier in possession of records or information concerning the patient to

 

 

furnish such information to BlueCross BlueShield of South Carolina upon request.

 

 

 

 

INSURED’S SIGNATURE

 

 

DATE

 

 

 

 

 

 

 

 

 

(11318) Rev. 3/13

Please see the other side of this form for mailing instructions.

 

 

 

please send this form to:

BlueCross BlueShield of South Carolina

P.O. Box 100605

Columbia, SC 29260-0605

In Columbia: 803-736-1576

In S.C. and Nationwide: 800-868-2520

before you mail your claim form, please remember to:

1.include the insured’s bin – beneits identiication number (the id number on your state health plan card);

2.sign and date the form; and

3.attach copies of itemized bills for services, including:

•diagnoses,

•date(s) service(s) received,

•procedure codes,

•provider name, and

•provider identiication number(s).

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.

How to Edit Form 11318 Online for Free

Using the online tool for PDF editing by FormsPal, you can fill in or edit Form 11318 right here and now. Our editor is constantly developing to grant the best user experience achievable, and that's thanks to our commitment to continual improvement and listening closely to user comments. By taking a few basic steps, it is possible to start your PDF editing:

Step 1: Press the orange "Get Form" button above. It is going to open up our tool so that you can start completing your form.

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This form requires specific details; to guarantee consistency, you need to take into account the suggestions just below:

1. Fill out your Form 11318 with a selection of necessary blank fields. Collect all of the information you need and ensure there's nothing forgotten!

The best ways to fill in Form 11318 portion 1

2. Right after finishing this part, go to the next stage and complete the necessary details in these blank fields - M Yes M No, Date coverage became effective, Is patient entitled to Medicare, Is patient actively working, Is the patient disabled, Is the patient retired, M Yes, M Yes, M Yes, M Yes, M No, M No, M No, M No, and If yes give the date of retirement.

Filling out section 2 in Form 11318

3. Completing INSUREDS SIGNATURE, DATE, Rev, and Please see the other side of this is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Form 11318 completion process outlined (part 3)

Always be extremely careful while completing DATE and Please see the other side of this, as this is where many people make errors.

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