Maryland State Claim Form PDF Details

Filing a health claim form in the State of Maryland, especially for state employees, is a process governed by specific instructions and requirements to ensure that the claims are processed efficiently and promptly. The Maryland State Employees Health Claim Form is designed for members of the State Employees Health Plan filing claims related to PPO, POS, and EPO services, primarily when services are rendered by non-participating providers. This detailed form requires the subscriber's and patient’s legal names, membership details, relationship to the subscriber, and comprehensive information concerning the medical service or treatment received, including descriptions of illnesses or injuries, dates of first symptoms, and whether the treatment was related to an accident or work-related injury. Furthermore, it solicits details on other health insurance coverage that may be applicable, such as Medicare Part A and B or other health benefits, ensuring a thorough assessment of the claim. Significantly, to facilitate a transparent and accountable process, claimants must certify the accuracy of their information, acknowledging the legal ramifications of submitting false claims. Alongside, the form instructs claimants to attach all itemized bills, and if applicable, an Explanation of Benefits from other insurers, to assist CareFirst BlueCross BlueShield in the accurate adjudication of the claim. This comprehensive approach underscored by the form highlights the emphasis on accuracy, completeness, and compliance within the framework of healthcare claim processing in Maryland.

QuestionAnswer
Form NameMaryland State Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmaryland employees claim form, maryland state of claim form, maryland health claim, md state of claim form

Form Preview Example

CUT5803-1S (10/14)

Do not write in this space

STATE OF MARYLAND EMPLOYEES HEALTH CLAIM FORM

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Subscriber’s Legal Name (Last, First, Middle Initial)

 

Patient’s Legal Name (Last, First, Middle Initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Membership Number

 

 

Patient’s Sex

 

 

Patient’s Relationship to Subscriber

 

 

 

 

 

 

 

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2

 

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q Male

q Female

 

q Self

q Spouse

q Child

q Other

 

Subscriber’s Address (Street)

q Check box if NEW address

Patient’s Date of Birth

Month

 

Date

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT: ALL QUESTIONS MUST BE ANSWERED

 

 

List those illnesses for which you are submitting bills and date of first symptom.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Was the treatment a result of an injury?

q Yes q No

Was the treatment a result of an automobile accident?

q Yes q No

 

 

Description of Accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Accident

 

Where Accident Occurred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was illness(es) or injury(ies) in any way work related?

q Yes

q No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does patient have Medicare?

 

 

 

 

 

Effective Date of Coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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HEALTH INSURANCE

 

 

a. Medicare Part A (Hospital Insurance)?

q Yes

q No

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

CLAIM NUMBER

 

 

 

 

 

 

 

 

 

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b. Medicare Part B (Physician’s Coverage)? q Yes

q No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In addition to coverage under this program, is patient covered under any other insurance providing health care benefits or services?

 

 

q Yes q No

If “Yes”, please complete:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. Name of Policy Holder

 

 

 

 

 

 

Relationship to Patient

 

 

 

 

 

 

 

 

 

 

b. Name of Insuring Co.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Policy or Certificate No.

 

 

 

 

 

 

d. Effective Date of Coverage

 

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Month Day

Year

 

 

e. Check type of coverage: q Hospital

q Surgical-Medical

q Major Medical

q Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

f. Check One: I have

q Family q Husband and Wife q Individual q Parent and Child coverage with this carrier.

 

 

g. Name and Address of Policy Holder’s Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above.

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Authorization is hereby given to any hospital, physician, or other provider which participated in any way in my care and treatment to release to CareFirst BlueCross BlueShield any medical information which they in their judgement deem necessary to the adjudication of this claim.

X

SIGNATURE OF SUBSCRIBER

DATE

HAVE YOU ATTACHED YOUR ITEMIZED BILLS?

Administrative Use Only

Do not write in this space

Provider#

 

Initials

CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association.

® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

Mail Administrator

P.O. Box 14115

Lexington, KY 40512-4115

STATE OF MARYLAND EMPLOYEES HEALTH CLAIM FORM

This form is to be used only by members of the State Employees Health Plan to file PPO, POS and EPO claims. While participating providers will bill CareFirst BlueCross BlueShield for services rendered, you may have claims to file yourself if you see non-participating providers.

• A copy of the bill on the provider’s letterhead stationary

IN ORDER FOR YOUR CLAIMS TO BE PROCESSED, THE FOLLOWING INFORMATION MUST BE SUBMITTED

The bill must include:

Provider’s full name, degree, address, phone # and CareFirst BlueCross BlueShield provider number if available.

Patient’s full name

Descriptions of each service or supply

Date of which each service was provided

The provider’s diagnosis, or patient’s chief complaint

The amount charged by the provider for each service provided

Bills in foreign language should be translated to English, foreign currency should be converted to American dollars

Original bills and receipts required for all services

Keep a copy of your bills and claim for your records

Provider’s signature is required

•A completed claim form. Please be sure to accurately complete all sections of the claim form. Always use one claim form per patient.

•When another insurance carrier (including Medicare) is paying your claim first, please submit a copy of their payment statement with your claim. These statements are sometimes called “Explanation of Benefits,” “Summary of Benefits,” “Explanation of Medicare Benefits.”

BILLS FOR THE FOLLOWING SERVICES SHOULD INCLUDE THIS ADDITIONAL INFORMATION

Office Visits:

Type of visit (brief, intermediate, extended, etc.)

Private Duty Nursing:

Dates and shifts worked, amount charged for each shift, prescribing Doctor’s name and degree,

 

and registration # of nurse.

Durable Medical Equipment:

Include the full purchase price of any rented equipment. A letter of medical necessity from your

(wheelchair, respirator, oxygen, etc.)

physician must be submitted with the claim.

X-rays:

Type of x-ray (chest, legs, etc.)

Blood Charges:

Include the number of pints received, charges for each, and the number of pints replaced by

 

donors. Indicate whether bill is for whole blood, plasma or derivatives.

General Anesthesia:

The length of time (in minutes) the patient was under general anesthesia must appear on the bill.

Accidental Injury Claims:

Must indicate the date on which the accident occurred.

Members of the Preferred Provider Option (PPO), Exclusive Provider Organization (EPO) and Point of Service (POS) – Note: Must have pre- authorization on file after the sixth visit for outpatient physical therapy, occupational therapy and after first visit for speech therapy. See your benefit booklet, section: Managed Care Authorization Program for more information.

CareFirst BlueCross BlueShield State of Maryland Member Service

1-800-225-0131

Access our website at www.carefirst.com/statemd

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