Personal Choice Out Network Claim Form PDF Details

Are you looking to manage and update your personal health insurance policy with convenience? Our Network Claim Form can help streamline the process of submitting and managing any type of request for coverage. We're here to provide an easy-to-use step by step guide on how you can use our network claim form, from filing a claim up to monitoring its status until it is fully processed. Read on to learn more - we've got all the information you need!

QuestionAnswer
Form NamePersonal Choice Out Network Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesibx 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

Form Preview Example

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.,

 

¨

 

C H O I C E

¨

 

 

 

 

 

 

a subsidiary of Independence Blue Cross Ð independent

 

 

 

 

 

 

 

 

 

licensees of the Blue Cross and Blue Shield Association.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please Mail To:

Personal Choice Claims

OUT-OF-NETWORK CLAIM FORM

 

 

 

 

 

 

P.O. Box 69352

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Harrisburg, PA 17106-9352

 

 

 

 

 

 

 

 

 

(see reverse side for instructions)

 

 

 

 

 

 

 

 

 

 

 

 

 

MEMBERÕS NAME (FIRST, MIDDLE, LAST)

 

 

 

IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESENT ADDRESS STREET

☐ NEW ADDRESS

 

 

CITY

 

 

 

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENTÕS NAME (FIRST, MIDDLE, LAST)

 

RELATIONSHIP OF PATIENT TO MEMBER

 

 

 

 

SEX

BIRTH

 

 

 

 

 

☐ SELF

☐ SPOUSE

☐ CHILD

 

☐ MALE

DATE

 

 

 

 

 

 

 

 

 

 

 

 

☐ HANDICAPPED DEPENDENT

☐ OTHER

 

☐ FEMALE

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¥ Does the PATIENT have additional health insurance benefits?

☐ NO

☐ YES

 

If yes, complete Part II:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICYHOLDERÕS NAME

 

 

 

 

BIRTH DATE

 

EMPLOYMENT STATUS OF POLICYHOLDER

 

 

 

 

 

 

 

 

 

 

 

☐ ACTIVE

☐ DISABLED

 

 

 

 

 

 

 

 

 

/

/

 

☐ RETIRED EFFECTIVE DATE

/

/

 

 

 

 

 

 

 

 

 

 

RELATIONSHIP OF POLICYHOLDER TO MEMBER

 

 

OTHER INSURANCE CARRIERÕS NAME

IDENTIFICATION NO

EFFECTIVE DATE

☐ SELF ☐ SPOUSE ☐ CHILD

☐ OTHER ________________

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE(S) OF COVERAGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

☐ HOSPITALIZATION

☐ MEDICAL-SURGICAL

 

☐ DENTAL

☐ VISION

 

☐ DRUG

 

☐ MAJOR MEDICAL

 

☐OTHER _____________________________________________________________________________________________________________________

CONTRACT COVERS

 

 

 

 

 

 

 

 

 

 

 

 

☐ POLICYHOLDER ONLY

 

☐ POLICYHOLDER AND SPOUSE

 

☐ POLICYHOLDER AND CHILD(REN)

☐ FAMILY

 

 

 

 

 

 

¥ Is the PATIENT entitled to benefits under MEDICARE HOSPITALIZATION Insurance (Part A)?

 

 

 

 

 

☐ NO

☐ YES

EFFECTIVE DATE

/

/

 

MEDICARE NUMBER ____________________

 

¥ Does the PATIENT receive benefits under MEDICARE MEDICAL Insurance (Part B)?

 

 

 

 

 

 

☐ NO

☐ YES

EFFECTIVE DATE

/

/

 

MEDICARE NUMBER ____________________

 

If you answered ÒYESÓ to either of the above, give employment status of the member listed in Part Ò1Ó:

 

 

 

 

 

☐ ACTIVE

☐ RETIRED

☐ DISABLED

 

 

 

 

 

 

 

¥ DESCRIBE CONDITIONS FOR WHICH YOU ARE REQUESTING BENEFITS AT THIS TIME:

 

 

 

 

 

TYPE OF INJURY/ILLNESS

 

NAME OF DOCTOR TREATING INJURY/ILLNESS

 

DATE OF FIRST SYMPTOMS

A.

_______________________________

____________________________________________________

/

/

_________________________

B.

_______________________________

____________________________________________________

/

/

_________________________

(Attach additional information, if necessary)

 

 

 

 

 

 

 

 

 

¥ WERE SERVICES RELATED TO HOSPITALIZATION?

☐ NO

☐ YES

If yes,

 

 

 

 

 

Give date of admission

/

/

 

 

 

Give date of discharge

/

/

 

 

 

Hospital Name ____________________________________________

Admitting Physician ________________________________________________

¥ WERE EXPENSES DUE TO AN ACCIDENT?

☐ NO

☐ YES

 

If yes, give type/place of accident:

 

 

 

 

Give date of accident

/

/

☐ Auto

☐ Work

 

☐ 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.

____________________________________________________________

_________________________

___________________________

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 Out-Of-Network provider who does not submit a claim for you.

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 out-of-network provider in full for the services, or supplies you are claiming, payment should be made to you (if you are our member). Please be sure to have the provider mark ÒPAID IN FULLÓ clearly on the bill.

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.

Out-of-network, non-participating providers may bill you for differences between the Plan allowance, which is the amount paid by Independence Blue Cross (IBC), and the providerÕs actual charge. This amount may be significant and it is not covered by IBC. Claims payments for out-of-network professional providers (physicians) are based on IBCÕs own fee schedule.

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