Maryland State Claim Form – Fill Out and Use This PDF

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