Have you ever filed an insurance claim? It can be a daunting process, but Samba Insurance Claim Form is here to help. We offer step-by-step instructions on how to file your claim, as well as tips and advice from our experts. So whether you're filing a car insurance claim or making a home insurance claim, we've got you covered.
In the table, there's some good information concerning the samba insurance claim form. It's worth spending some time to read through this before starting submitting your form.
Question | Answer |
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Form Name | Samba Insurance Claim Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | samba federal health plan claims address, samba claims address, samba cigna, samba insurance |
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MAIL SAMBA CLAIMS TO: |
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CIGNA |
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P. O. Box 188007 |
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Chattanooga, TN 37422 |
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HEALTH INSURANCE CLAIM FORM |
(301) |
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INSTRUCTIONS ARE SHOWN ON REVERSE SIDE. |
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1. MEDICARE |
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MEDICAID |
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CHAMPUS |
CHAMPVA |
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GROUP |
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FECA |
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OTHER |
1a. INSURED’S I.D. NUMBER |
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(FOR PROGRAM IN ITEM 1) |
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HEALTH PLAN |
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BLK LUNG |
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(Medicare #) |
(Medicaid #) |
(Sponsor’s SSN) |
(VA File #) |
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X (SSN or ID) |
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(SSN) |
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(ID) |
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2. PATIENT’S NAME (Last Name, First Name, Middle Initial) |
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3. PATIENT’S BIRTH DATE |
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4. INSURED’S NAME (Last Name, First Name, Middle Initial) |
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SEX |
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5. PATIENT’S ADDRESS (No., Street) |
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6. PATIENT RELATIONSHIP TO INSURED |
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7. INSURED’S ADDRESS (No., Street) |
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Self |
Spouse |
Child |
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Other |
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CITY |
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STATE |
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8. PATIENT STATUS |
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CITY |
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STATE |
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Single |
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Married |
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Other |
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ZIP CODE |
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TELEPHONE (Include Area Code) |
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ZIP CODE |
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TELEPHONE (Include Area Code) |
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( |
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Employed |
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( |
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Student |
Student |
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9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) |
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10. IS PATIENT’S CONDITION RELATED TO: |
11. INSURED’S POLICY GROUP NUMBER |
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a. EMPLOYMENT? (CURRENT OR PREVIOUS) |
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a. OTHER INSURED’S POLICY OR GROUP NUMBER |
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a. INSURED’S DATE OF BIRTH |
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SEX |
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YES |
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NO |
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b. AUTO ACCIDENT? |
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PLACE (State) |
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b. OTHER INSURED’S DATE OF BIRTH |
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SEX |
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b. EMPLOYER’S NAME |
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YES |
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NO |
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c. EMPLOYER’S NAME |
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c. OTHER ACCIDENT? |
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c. INSURANCE PLAN NAME OR PROGRAM NAME |
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YES |
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NO |
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d. INSURANCE PLAN NAME OR PROGRAM NAME |
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10d. RESERVED FOR LOCAL USE |
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d. IS THERE ANOTHER HEALTH BENEFIT PLAN? |
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YES |
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NO |
If yes, return to and complete item 9 |
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12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize the release of any medical or other information necessary to |
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE. I authorize |
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process this claim. |
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payment of medical benefits to the undersigned physician or supplier for |
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services described below. |
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Signed |
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Date |
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Signed |
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14. DATE OF CURRENT: |
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ILLNESS (First Symptom) OR |
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15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, |
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION |
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INJURY (Accident) OR |
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GIVE FIRST DATE |
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PREGNANCY (LMP) |
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FROM |
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17. NAME OF REFERRING PROVIDER OR OTHER SOURCE |
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17a. |
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18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES |
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17b. |
NPI# |
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19. RESERVED FOR LOCAL USE |
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20. OUTSIDE LAB? |
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$CHARGES |
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YES |
NO |
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21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1,2,3 or 4 to Item 24E by Line) |
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22. MEDICAID RESUBMISSION |
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CODE |
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ORIGINAL REF. NO. |
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1. |
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3. |
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23. PRIOR AUTHORIZATION NUMBER |
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2. |
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4. |
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24. A. |
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DATE(S) OF SERVICE |
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B. |
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C. |
D. PROCEDURES, SERVICES, OR SUPPLIES |
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E. |
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F. |
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G. |
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H. |
I. |
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J. |
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From |
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To |
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Place of |
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(Explain Unusual Circumstances) |
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DIAGNOSIS |
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DAYS |
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EPSDT |
ID. |
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RENDERING |
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MM |
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YY |
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MM |
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DD |
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Service |
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EMG |
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CPT/HCPCS |
MODIFIER |
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POINTER |
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$CHARGES |
OR |
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Family |
QUAL. |
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PROVIDER ID.# |
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UNITS |
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Plan |
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NPI # |
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NPI #
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NPI # |
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NPI # |
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NPI # |
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NPI # |
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25. FEDERAL TAX I.D. NUMBER |
SSN EIN |
26. PATIENT’S ACCOUNT NO. |
27. ACCEPT ASSIGNMENT? |
28. TOTAL CHARGE |
29. AMOUNT PAID |
30. BALANCE DUE |
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(For govt. claims, see back) |
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YES |
NO |
$ |
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$ |
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$ |
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31. SIGNATURE OF PHYSICIAN OR SUPPLIER |
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32. SERVICE FACILITY LOCATION INFORMATION |
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33. BILLING PROVIDER INFORMATION & PHONE # |
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INCLUDING DEGREES OR CREDENTIALS |
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(I certify that the statements on the reverse |
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apply to this bill and are made a part thereof.) |
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SIGNED |
DATE |
a. |
NPI |
b. |
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a. |
NPI |
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b. |
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PATIENT AND INSURED INFORMATION
PHYSICIAN OR SUPPLIER INFORMATION
PLEASE PRINT OR TYPE
HEALTH INSURANCE CLAIM FORM INSTRUCTIONS
TO THE INSURED:
1.Complete items (1) through (13).
2.Attach itemized bills to the Claim Form. You do not need to have the provider of service complete the claim form if you attach fully itemized bills and/or receipts. Bills and receipts must show:
•Name of patient and relationship to member
•Plan identification number of the member
•Name and address of physician or supplier providing the service or supply
•Date service or supply was furnished
•Type of service or supply and the charge
•Diagnosis
In addition:
•A copy of the Explanation of Benefits from any primary payer (such as Medicare) must be sent with your claim.
•Claims for rental or purchase of durable medical equipment, private duty nursing and physical, occupation and speech therapy require a written statement from the doctor specifying the medical necessity for the service or supply and the length of time needed.
•Claims for overseas (foreign) services should include an English translation. Charges should be converted to U.S. dollars using the exchange rate applicable at the time the expense was incurred.
Cancelled checks, cash register receipts or balance due statements are not acceptable.
TO THE PHYSICIAN OR SUPPLIER:
1. The physician or supplier must complete items (14) through (33).
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(PARTIAL LIST) |
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PLACE OF SERVICE CODES: |
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TYPE OF SERVICE CODES: |
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11 - Office |
41 |
- |
1 |
- Medical Care |
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12 |
- Home |
42 |
- |
2 |
- Surgery |
21 |
- Inpatient Hospital |
51 |
- Inpatient Psychiatric Facility |
3 |
- Consultation |
22 |
- Outpatient Hospital |
52 |
- Psychiatric Partial Hospitalization |
4 |
- Diagnostic |
23 |
- Emergency Room Hospital |
55 |
- Substance Abuse Treatment Center |
5 |
- Diagnostic Lab |
24 |
- Ambulatory Surgery Center |
56 |
- Psychiatric Treatment Center |
6 |
- Radiation/Chemotherapy |
31 |
- Skilled Nursing Home |
61 |
- Inpatient Rehabilitation Facility |
7 |
- Anesthesia |
32 |
- Nursing Facility |
62 |
- Outpatient Rehabilitation Facility |
8 |
- Assistant Surgery |
33 |
- Custodial Care Facility |
81 |
- Independent Lab |
F - ASC Facility Charge |
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34 |
- Hospice |
99 |
- Other |
T - Psychological Therapy |
0808