Samba Insurance Claim Form PDF Details

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.

QuestionAnswer
Form NameSamba Insurance Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessamba federal health plan claims address, samba claims address, samba cigna, samba insurance

Form Preview Example

 

 

 

 

MAIL SAMBA CLAIMS TO:

 

 

 

 

CIGNA

 

 

 

 

P. O. Box 188007

 

 

 

 

Chattanooga, TN 37422

 

 

 

 

HEALTH INSURANCE CLAIM FORM

(301) 984-1440 (800) 638-6589

INSTRUCTIONS ARE SHOWN ON REVERSE SIDE.

 

1. MEDICARE

 

 

 

 

MEDICAID

 

 

CHAMPUS

CHAMPVA

 

GROUP

 

 

FECA

 

 

 

 

OTHER

1a. INSURED’S I.D. NUMBER

 

(FOR PROGRAM IN ITEM 1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH PLAN

 

BLK LUNG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Medicare #)

(Medicaid #)

(Sponsor’s SSN)

(VA File #)

 

X (SSN or ID)

 

(SSN)

 

 

 

 

(ID)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

 

 

 

 

 

 

3. PATIENT’S BIRTH DATE

 

 

 

 

 

 

 

 

4. INSURED’S NAME (Last Name, First Name, Middle Initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

 

 

YY

 

 

 

SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. PATIENT’S ADDRESS (No., Street)

 

 

 

 

 

 

 

 

 

 

6. PATIENT RELATIONSHIP TO INSURED

 

 

 

7. INSURED’S ADDRESS (No., Street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

Spouse

Child

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

8. PATIENT STATUS

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

Married

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

 

 

TELEPHONE (Include Area Code)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP CODE

 

 

 

 

 

TELEPHONE (Include Area Code)

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

Employed

 

Full-Time

Part-Time

 

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Student

Student

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

 

 

 

10. IS PATIENT’S CONDITION RELATED TO:

11. INSURED’S POLICY GROUP NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. EMPLOYMENT? (CURRENT OR PREVIOUS)

 

 

 

 

 

 

 

 

 

 

 

 

 

a. OTHER INSURED’S POLICY OR GROUP NUMBER

 

 

 

 

 

 

a. INSURED’S DATE OF BIRTH

 

 

SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. AUTO ACCIDENT?

 

 

PLACE (State)

 

 

 

 

 

 

 

 

 

 

 

 

b. OTHER INSURED’S DATE OF BIRTH

 

 

SEX

 

 

 

 

 

 

 

 

b. EMPLOYER’S NAME

 

 

 

 

 

 

 

 

 

 

MM

 

DD

YY

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. EMPLOYER’S NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. OTHER ACCIDENT?

 

 

 

 

 

 

 

 

 

c. INSURANCE PLAN NAME OR PROGRAM NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. INSURANCE PLAN NAME OR PROGRAM NAME

 

 

 

 

 

 

 

 

10d. RESERVED FOR LOCAL USE

 

 

 

d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

If yes, return to and complete item 9 a-d

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

process this claim.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

payment of medical benefits to the undersigned physician or supplier for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

services described below.

 

 

 

 

 

 

 

 

Signed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

Signed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. DATE OF CURRENT:

 

ILLNESS (First Symptom) OR

 

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS,

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

 

MM

DD YY

 

 

INJURY (Accident) OR

 

 

 

 

GIVE FIRST DATE

MM

DD

 

 

 

 

YY

 

 

 

 

 

MM

DD

 

 

YY

 

MM

DD

YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREGNANCY (LMP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

 

 

 

17a.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

 

 

YY

 

MM

DD

YY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17b.

NPI#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. RESERVED FOR LOCAL USE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. OUTSIDE LAB?

 

 

 

 

$CHARGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1,2,3 or 4 to Item 24E by Line)

 

 

 

 

 

 

 

 

 

22. MEDICAID RESUBMISSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CODE

 

 

 

 

ORIGINAL REF. NO.

 

 

1.

 

 

.

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23. PRIOR AUTHORIZATION NUMBER

 

 

 

 

2.

 

 

.

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. A.

 

DATE(S) OF SERVICE

 

 

B.

 

C.

D. PROCEDURES, SERVICES, OR SUPPLIES

 

 

E.

 

F.

 

G.

 

 

H.

I.

 

 

J.

 

 

 

 

From

 

 

 

 

 

 

 

To

 

 

Place of

 

 

 

 

 

 

 

(Explain Unusual Circumstances)

 

 

 

DIAGNOSIS

 

 

 

DAYS

 

 

EPSDT

ID.

 

RENDERING

MM

DD

 

 

YY

 

MM

 

DD

 

YY

Service

 

EMG

 

CPT/HCPCS

MODIFIER

 

 

 

 

 

POINTER

 

$CHARGES

OR

 

 

Family

QUAL.

 

PROVIDER ID.#

 

 

 

 

 

 

 

 

 

 

 

 

 

UNITS

 

Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NPI #

 

 

 

 

 

NPI #

 

 

 

 

 

 

NPI #

 

 

 

 

 

 

NPI #

 

 

 

 

 

 

NPI #

 

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

 

 

 

(For govt. claims, see back)

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

$

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31. SIGNATURE OF PHYSICIAN OR SUPPLIER

 

 

 

 

 

32. SERVICE FACILITY LOCATION INFORMATION

 

33. BILLING PROVIDER INFORMATION & PHONE #

 

INCLUDING DEGREES OR CREDENTIALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(I certify that the statements on the reverse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

apply to this bill and are made a part thereof.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNED

DATE

a.

NPI

b.

 

a.

NPI

 

b.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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).

 

 

 

(PARTIAL LIST)

 

 

PLACE OF SERVICE CODES:

 

 

TYPE OF SERVICE CODES:

11 - Office

41

- Ambulance-Land

1

- Medical Care

12

- Home

42

- Ambulance-Air, Water

2

- Surgery

21

- Inpatient Hospital

51

- Inpatient Psychiatric Facility

3

- Consultation

22

- Outpatient Hospital

52

- Psychiatric Partial Hospitalization

4

- Diagnostic X-Ray

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

34

- Hospice

99

- Other

T - Psychological Therapy

0808

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