When seeking medical care outside of your insurance network, the Personal Choice Out Network Claim Form becomes a vital tool for reimbursement. This form, utilized by members of Independence Blue Cross and its subsidiary, QCC Insurance Co., allows members to submit claims for services received from providers who do not directly bill the insurance. The process insists on attaching all relevant receipts and thoroughly completing several sections detailing the member/patient information, any other insurance coverage, the patient's condition, and an authorization statement. Additionally, it requires the member to certify the authenticity and completeness of the information provided, warning against fraud, which carries severe penalties. The process emphasizes the importance of attaching itemized bills that clearly state the services provided, the charges, and the diagnosis, ensuring that the claim is processed efficiently. Moreover, for expenses already paid out-of-pocket, the form facilitates reimbursement directly to the member. This form is a crucial link between out-of-network services and the member's ability to receive benefits for those services, underlining the importance of precision and honesty in its completion.
Question | Answer |
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Form Name | Personal Choice Out Network Claim Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | ibx out of network claim form, personal choice out of network claim form 2019, personal choice out of network claim, independence personal choice out of newtowk claim form |
HERE
RECEIPTS
ATTACH
I.
MEMBER/PATIENT
II.
OTHER INSURANCE
III.
PATIENTÕS CONDITION
IV.
AUTHORIZATION
Independence
Blue Cross
Benefits underwritten or administered by QCC Insurance Co., |
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C H O I C E |
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a subsidiary of Independence Blue Cross Ð independent |
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licensees of the Blue Cross and Blue Shield Association. |
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Please Mail To: |
Personal Choice Claims |
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P.O. Box 69352 |
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Harrisburg, PA |
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(see reverse side for instructions) |
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MEMBERÕS NAME (FIRST, MIDDLE, LAST) |
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IDENTIFICATION NUMBER |
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PRESENT ADDRESS STREET |
☐ NEW ADDRESS |
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CITY |
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STATE |
ZIP CODE |
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PATIENTÕS NAME (FIRST, MIDDLE, LAST) |
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RELATIONSHIP OF PATIENT TO MEMBER |
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SEX |
BIRTH |
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☐ SELF |
☐ SPOUSE |
☐ CHILD |
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☐ MALE |
DATE |
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☐ HANDICAPPED DEPENDENT |
☐ OTHER |
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☐ FEMALE |
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¥ Does the PATIENT have additional health insurance benefits? |
☐ NO |
☐ YES |
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If yes, complete Part II: |
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POLICYHOLDERÕS NAME |
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BIRTH DATE |
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EMPLOYMENT STATUS OF POLICYHOLDER |
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☐ ACTIVE |
☐ DISABLED |
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☐ RETIRED EFFECTIVE DATE |
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RELATIONSHIP OF POLICYHOLDER TO MEMBER |
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OTHER INSURANCE CARRIERÕS NAME |
IDENTIFICATION NO |
EFFECTIVE DATE |
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☐ SELF ☐ SPOUSE ☐ CHILD |
☐ OTHER ________________ |
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TYPE(S) OF COVERAGE |
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☐ HOSPITALIZATION |
☐ |
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☐ DENTAL |
☐ VISION |
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☐ DRUG |
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☐ MAJOR MEDICAL |
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☐OTHER _____________________________________________________________________________________________________________________
CONTRACT COVERS |
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☐ POLICYHOLDER ONLY |
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☐ POLICYHOLDER AND SPOUSE |
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☐ POLICYHOLDER AND CHILD(REN) |
☐ FAMILY |
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¥ Is the PATIENT entitled to benefits under MEDICARE HOSPITALIZATION Insurance (Part A)? |
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☐ NO |
☐ YES |
EFFECTIVE DATE |
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MEDICARE NUMBER ____________________ |
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¥ Does the PATIENT receive benefits under MEDICARE MEDICAL Insurance (Part B)? |
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☐ NO |
☐ YES |
EFFECTIVE DATE |
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MEDICARE NUMBER ____________________ |
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If you answered ÒYESÓ to either of the above, give employment status of the member listed in Part Ò1Ó: |
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☐ ACTIVE |
☐ RETIRED |
☐ DISABLED |
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¥ DESCRIBE CONDITIONS FOR WHICH YOU ARE REQUESTING BENEFITS AT THIS TIME: |
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TYPE OF INJURY/ILLNESS |
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NAME OF DOCTOR TREATING INJURY/ILLNESS |
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DATE OF FIRST SYMPTOMS |
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A. |
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____________________________________________________ |
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_________________________ |
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B. |
_______________________________ |
____________________________________________________ |
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_________________________ |
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(Attach additional information, if necessary) |
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¥ WERE SERVICES RELATED TO HOSPITALIZATION? |
☐ NO |
☐ YES |
If yes, |
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Give date of admission |
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Give date of discharge |
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Hospital Name ____________________________________________ |
Admitting Physician ________________________________________________ |
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¥ WERE EXPENSES DUE TO AN ACCIDENT? |
☐ NO |
☐ YES |
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If yes, give type/place of accident: |
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Give date of accident |
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☐ Auto |
☐ Work |
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☐ Other (specify) _________________________________________________ |
I certify that the information provided on this claim form is correct and complete, and that I am claiming benefits only for charges actually incurred by the patient named. I authorize any hospital, physician or other provider who participated in the care and treatment of the patient to release to Independence Blue Cross all medical or other information requested for the processing of this claim. I hereby agree to reimburse Independence Blue Cross in full should this claim be incorrectly paid. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
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MEMBERÕS SIGNATURE |
DATE |
(AREA CODE) HOME PHONE |
(AREA CODE) WORK PHONE |
1519 D 2/07
INSTRUCTIONS:
Remember: Personal Choice¨ Network providers will submit a claim for you. This claim form should only be used when you see an
1.Attach all itemized bills to this claim form. Bills should include the following information:
¥Name, address, and telephone number (on official bill head) of the PROVIDER rendering the service or supplying the item.
¥PATIENTÕS full name
¥DESCRIPTION of each service, or supply
¥DATE AND AMOUNT CHARGED for each service, or supply
¥DIAGNOSIS
2.When you have already paid the
3.Please be sure that a PHYSICIANÕS MEDICAL CERTIFICATION accompanies bills for:
¥Purchase or Rental of Medical Equipment
4.If submitting expenses for more than one family member, please use a SEPARATE claim form for each person.
5.Complete the entire claim form (have your physician complete the appropriate section, if necessary) and be sure to include the information requested above. This will avoid unnecessary delays in processing your claim. Keep a copy of this form and itemized bills for your records.
6.If you have QUESTIONS regarding the completion of this claim form, please contact Personal Choice Member Services at the telephone number shown on your ID Card.