Health Benefits Claim Form CareFirst BlueCross BlueShield 31904 CF Blue Preferred Claims

User Manual: 31904

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CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
CUT0165-1S (2/09)
HEALTH BENEFITS CLAIM FORM
PLEASE COMPLETE A SEPARATE CLAIM FORM FOR EACH FAMILY MEMBER.
(SEE REVERSE SIDE FOR FILING INFORMATION)
PLEASE COMPLETE EACH NUMBERED ITEM - FAILURE TO DO SO MAY RESULT IN DELAYS IN
PROCESSING YOUR CLAIM
PLEASE TYPE OR PRINT
16.LIST BELOW ONLY THOSE CHARGES BEING CLAIMED AND ATTACH ORIGINAL ITEMIZED BILLS FROM THE PROVIDERS FOR THESE SERVICES
DIAGNOSIS
(IF MORE THAN ONE) FROM DATE TO DATE CHARGE
NAME(S) OF PROVIDER(S) DESCRIPTION(S) OF SERVICE(S)
$
A. .
$
B. .
$
C. .
$
D. .
.
18. THIS CLAIM FORM MUST BE SIGNED.
IF NOT, IT WILL BE RETURNED.
I request benefits for these expenses and certify that the above information
is correct and that the foregoing expenses were incurred for the above
named patient. I authorize any physician, nurse, hospital or other providers
or suppliers in possession of information concerning the patient to furnish
such information to CareFirst BlueCross BlueShield upon request.
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
(SEE REVERSE)
I, the undersigned, authorize CareFirst BlueCross BlueShield to make
payment for benefits due herein to
Subscriber Signature Date
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a
loss or benefit or who knowingly and willfully presents false information in an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
Name of Provider
Provider’s Tax or Social Security Number
Name of Provider
Provider’s Tax or Social Security Number
Subscriber Signature Date
MO DAY YEAR MO DAY YEAR
17.
MO DAY YEAR
MO DAY YEAR
1. IDENTIFICATION NUMBER 2.GROUP NUMBER OR ENROLLMENT CODE 3.PATIENT’S NAME (FIRST, MIDDLE INITIAL, LAST)
4. PATIENT’S DATE OF BIRTH
MO DAY YEAR
5. PATIENT’S SEX
FEMALE q MALE q
6. PATIENT’S RELATIONSHIP TO SUBSCRIBER:
EE SP CH
SELF q SPOUSE q CHILD q OTHER q EXPLAIN:
7. SUBSCRIBER’S NAME (FIRST, MIDDLE INITIAL, LAST) 8.DAYTIME TELEPHONE NUMBER (INCLUDE AREA CODE)
15.STATE THE DIAGNOSIS, SYMPTOMS, ILLNESS OR INJURY FOR THE EXPENSES CLAIMED
BEFORE? NO q YES q IF YES, WHEN GIVE DATE PHYSICIAN FIRST SEEN
NAME & ADDRESS OF
ADMITTING PHYSICIAN
DISCHARGE
ADMISSION DATE
WAS ANOTHER PARTY AT FAULT? NO q YES q
IF AN ACCIDENT, GIVE THE DATE OF THE ACCIDENT
MO DAY YEAR IF YES, ATTACH A STATEMENT WITH DETAILS (SEE
ACCIDENTAL INJURY ON THE REVERSE SIDE)
IF MEDICAL EMERGENCY GIVE DATE SYMPTOMS BEGAN
9. SUBSCRIBER’S ADDRESS (STREET, CITY, STATE, ZIP CODE) CHECK IF NEW ADDRESS q
10. IS PATIENT COVERED UNDER OTHER HEALTH INSURANCE? NO q YES q IF YES, NAME OF OTHER INSURANCE COMPANY
NAME OF POLICY HOLDER POLICY OR IDENTIFICATION NUMBER
IF THE SUBSCRIBER IS MARRIED, IS THE SPOUSE EMPLOYED? NO q YES q
IS PATIENT COVERED UNDER MEDICARE? NO q YES q
IF YES, PART A q PART B q MEDICARE HIC NUMBER
IF YES, GIVE THE NAME OF THE SPOUSE’S EMPLOYER
IS PATIENT ACTIVELY EMPLOYED? NO q YES q IF YES, NAME OF EMPLOYER 2
AUTO ACCIDENT? NO q YES q ANY OTHER ACCIDENTAL INJURY? NO q YES q WORK RELATED ACCIDENT OR CONDITION? NO q YES q
11. WAS PATIENT’S CONDITION DUE TO:
MEDICAL EMERGENCY? NO q YES q MO DAY YEAR
12.WAS PATIENT HOSPITALIZED? NO q YES q IF YES, COMPLETE THE FOLLOWING: NAME OF HOSPITAL
13.ARE BILLS FOR A CONSULTATION ATTACHED? NO q YES q IF YES, GIVE NAME OF PHYSICIAN WHO REQUESTED THE CONSULTATION
WAS THE CONSULTATION REQUESTED TO OBTAIN A SECOND SURGICAL OPINION? NO q YES q
WAS SURGERY RECOMMENDED? NO q YES q
14.ARE BILLS FOR MATERNITY ATTACHED? NO q YES q IF YES, WHAT IS THE DATE OF THE LAST MENSTRUAL PERIOD?
GIVE DATE SYMPTOM(S) FIRST STARTED
HAS PATIENT HAD THESE SYMPTOMS/CONDITION
MO DAY YEAR MO DAY YEAR
MO DAY YEAR
MO DAY YEAR
MO DAY YEAR
MO DAY YEAR
$.
( ) —
2
*THIS FORM CAN ALSO BE USED FOR FILING CLAIMS FOR CAREFIRST BLUECHOICE OPT-OUT PLUS.
INSTRUCTIONS
THIS FORM IS TO BE USED TO SUBMIT A CLAIM FOR SERVICES UNDER YOUR HEALTH PLAN.
TO AVOID HAVING YOUR CLAIM RETURNED:
3 PREPARE A SEPARATE CLAIM FORM FOR EACH FAMILY MEMBER.
3 COMPLETE ALL OF THE INFORMATION REQUESTED IN ITEMS 1 THRU 18.
3 IF YOU PREFER THAT BENEFITS BE PAID TO THE PROVIDER OF SERVICE BE SURE
TO COMPLETE THE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS ON THE FRONT.
CAREFIRST BLUECROSS BLUESHIELD RESERVES THE RIGHT TO MAKE PAYMENT DIRECTLY
TO THE SUBSCRIBER AND TO REFUSE TO HONOR THE ASSIGNMENT OF ANY CLAIM TO ANY
PERSON OR PARTY.
EACH PROVIDER’S ORIGINAL ITEMIZED BILL MUST BE ATTACHED AND CONTAIN:
3 THE LETTERHEAD INDICATING THE
NAME AND ADDRESS OF THE
PERSON OR ORGANIZATION
PROVIDING THE SERVICE
3 THE NAME OF THE PATIENT
RECEIVING THE SERVICE
3 THE DATE FOR EACH INDIVIDUAL
SERVICE (A RANGE OF DATES
CANNOT BE ACCEPTED)
3 THE CHARGE FOR EACH INDIVIDUAL
SERVICE
3 A DESCRIPTION OF EACH SERVICE
ON EACH BILL, PLEASE CROSS OUT ANY CHARGES THAT WERE INCLUDED ON A PREVIOUS CLAIM. PERSONAL ITEMIZATIONS,
CASH REGISTER RECEIPTS, CREDIT CARD RECEIPTS AND CANCELLED CHECKS ARE NOT ACCEPTABLE. ITEMIZED BILLS CANNOT
BE RETURNED.
IN ADDITION TO THE ABOVE REQUIREMENTS, THE FOLLOWING INFORMATION WILL BE NEEDED:
ACCIDENTAL INJURY - STATEMENTS MUST CONTAIN DETAILS AS TO WHEN, WHERE AND THE MANNER IN WHICH THE INJURY OCCURRED,
AS WELL AS THE NAME AND ADDRESS OF THE PARTY AT FAULT.
PRESCRIPTION DRUGS - BILLS MUST INCLUDE THE PRESCRIPTION NUMBER, THE NAME OF THE DRUG AND THE NAME OF THE PHYSICIAN
PRESCRIBING THE MEDICATION.
PRIVATE DUTY NURSING - BILLS MUST INCLUDE THE SHIFT WORKED, THE CHARGE PER HOUR, THE NUMBER OF HOURS WORKED,
THE NURSE’S PROFESSIONAL STATUS, PROFESSIONAL LICENSE NUMBER AND FAMILY RELATIONSHIP TO THE PATIENT, IF ANY. A STATEMENT
FROM THE ATTENDING PHYSICIAN MUST ACCOMPANY THE CLAIM. THE STATEMENT SHOULD EXPLAIN THE MEDICAL NECESSITY OF THE
SERVICE AND THE AUTHORIZATION FOR IT.
PROSTHETIC APPLIANCES AND THE RENTAL OR PURCHASE OF DURABLE MEDICAL EQUIPMENT - A STATEMENT FROM THE ATTENDING
PHYSICIAN MUST ACCOMPANY THE CLAIM. THE STATEMENT SHOULD EXPLAIN THE MEDICAL NECESSITY OF THE EQUIPMENT AND THE
PHYSICIAN’S AUTHORIZATION FOR IT.
PSYCHOTHERAPY - BILLS MUST INCLUDE THE LENGTH OF THE SESSION, THE TYPE OF SESSION AND THE PROVIDER’S PROFESSIONAL STATUS.
IF THE PROVIDER IS OTHER THAN A MEDICAL DOCTOR, THE PROVIDER’S PROFESSIONAL LICENSE NUMBER MUST ALSO BE GIVEN.
FOR PATIENTS COVERED BY ANOTHER INSURANCE CARRIER OR MEDICARE - IF THE PATIENT IS CLAIMING BENEFITS FOR ANY CHARGES THAT
ARE ELIGIBLE FOR BENEFITS UNDER ANY OTHER HEALTH INSURANCE POLICY OR MEDICARE PART A AND/OR PART B, THE EXPLANATION OF
BENEFITS FORM FURNISHED BY THE OTHER CARRIER PERTAINING TO THESE CHARGES MUST BE INCLUDED WITH THE ITEMIZED BILLS. A
CLEAR PHOTOCOPY OF THE OTHER CARRIER’S EXPLANATION OF BENEFITS FORM IS ACCEPTABLE IN PLACE OF THE ORIGINAL DOCUMENT.
FOR SERVICE RECEIVED OUTSIDE THE CAREFIRST BLUECROSS BLUESHIELD SERVICE AREA (MARYLAND, WASHINGTON DC AND NORTHERN
VIRGINIA) THE CLAIM FORM AND ALL RELATED MATERIALS SHOULD BE SUBMITTED TO YOUR LOCAL BLUE CROSS AND BLUE SHIELD PLAN.
PLEASE REFER TO THE FOLLOWING PAGES FOR A LISTING OF THE LOCAL BLUES PLANS IN YOUR AREA.
BEFORE SUBMITTING YOUR CLAIM, PLEASE BE SURE THAT:
1. THE CLAIM FORM IS FULLY COMPLETED AND SIGNED.
2. THE ITEMIZED BILLS ARE ATTACHED.
3. YOU HAVE KEPT COPIES OF EACH DOCUMENT AND
BILL FOR YOUR PERSONAL RECORDS
CUT0165-1S (2/09)
CareFirst BlueCross BlueShield
10455 Mill Run Circle
Owings Mills, MD 21117
When submitting claims for service from a non-participating provider received
outside of the CareFirst BlueCross BlueShield service area (Maryland, Washington DC
and northern Virginia) you must send your completed claim form to your local Blue Cross
and Blue Shield plan. You must include your 3 digit prex and your member ID number
when submitting your claim.
For the appropriate address of your local plan, please refer to the directory below.
ALABAMA
Blue Cross and Blue Shield of Alabama
Attn: Jim Deane
450 Riverchase Parkway East
Brimingham, AL 35244
ALASKA
Premera Blue Cross
P.O. Box 91080
Seattle, WA 98111
ARIZONA
Blue Cross and Blue Shield of Arizona
P.O. Box 2924
Phoenix, Arizona 85062-2924
ARKANSAS
Arkansas Blue Cross and Blue Shield
P.O. Box 2181
Little Rock, AR 72203
CALIFORNIA
Blue Cross of California
P.O. Box 60007
Los Angeles, CA 90060-0007
CALIFORNIA
Blue Shield of California
P.O. Box 1505
Red Bluff, CA 96080-1505
COLORADO
Anthem Blue Cross and Blue Shield
P.O. Box 5747
Denver, CO 80217-5747
CONNECTICUT
Anthem Blue Cross and Blue Shield
P.O. Box 533
North Haven, CT 06473-0533
DELAWARE
Blue Cross Blue Shield of Delaware
P.O. Box 8831
Wilmington, DE 19899-8831
DISTRICT OF COLUMBIA
CareFirst BlueCross BlueShield
Mail Administrator
P.O. Box 14116
Lexington, KY 40512-4116
FLORIDA
Blue Cross and Blue Shield of Florida
Attn: Deb Rosendale
4800 Deerwood Campus Parkway
Dcc 200 3rd oor
Jacksonville FL, 32246
GEORGIA
Blue Cross and Blue Shield of Georgia
P.O. Box 9907
Cols, GA 31904
HAWAII
Blue Cross and Blue Shield of Hawaii
HMSA--BlueCard Department
Attn: Misrouted Claims
P.O. Box 2970
Honolulu, HI 96802
IDAHO
Blue Cross of Idaho Health Service
Attn: ITS BlueCard Department
3000 E. Pine Ave
Meridian, ID 83642
IDAHO
Regence BlueShield of Idaho
P.O. Box 31603
Salt Lake City, UT 84131-0603
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. and is an independent licensee of the
Blue Cross and Blue Shield Association ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. and is an independent licensee of the
Blue Cross and Blue Shield Association ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
ILLINOIS
Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, IL 60680-4112
INDIANA
Anthem Blue Cross and Blue Shield Indiana
Anthem Document Management
P.O.Box 31780
Louisville, KY 40233
IOWA
Wellmark Blue Cross and Blue Shield
636 Grand Avenue, Station 39
Des Moines, Iowa 50309
JAMAICA
Blue Cross of Jamaica
The BlueCard Unit
Claims Department
85 Hope Road, Kingston 6
Jamaica, West Indies
KANSAS
Blue Cross and Blue Shield of Kansas
1133 SW Topeka Boulevard
P.O. Box 239
Topeka, KS 66629-0001
KENTUCKY
Anthem Blue Cross and Blue Shield
Anthem Document Management
P.O.Box 31780
Louisville, KY 40233
LOUISIANA
Blue Cross and Blue Shield of Louisiana
P.O. Box 98029
Baton Rouge, LA 70898-9029
MAINE
Anthem Blue Cross and Blue Shield
Anthem Blue Cross and Blue Shield
P.O. Box 533
North Haven, CT 06473
MARYLAND
CareFirst BlueCross BlueShield
Mail Administrator
P.O. Box 14116
Lexington, KY 40512-4116
MASSACHUSETTS
Blue Cross and Blue Shield of MA
Attn:BlueCard Claims Department
P.O. Box 986025
Boston, MA 02298
MINNESOTA
Blue Cross and Blue Shield of Minnesota
Route S201
P.O. Box 64560
St. Paul, MN 55164-0560
MISSISSIPPI
Blue Cross and Blue Shield of Mississippi
P.O. Box 1043
Jackson, MS 39215-1043
MISSOURI
Blue Cross and Blue Shield of Kansas City
Attn: NASCO Unit
P.O. Box 419016
Kansas City, MO 64141-6016
MISSOURI
Blue Cross and Blue Shield of Missouri
1831 Chestnut Street
St. Louis, MO 63103
MONTANA
Blue Cross and Blue Shield of Montana
P.O. Box 5004
Great Falls, MT 59405
NEBRASKA
Blue Cross and Blue Shield of Nebraska
7261 Mercy Road
Omaha, NE 68180-0001
NEVADA
Anthem Blue Cross and Blue Shield
P.O. Box 5747
Denver, CO 80217-5747
NEW HAMPSHIRE
Anthem Blue Cross and Blue Shield
3000 Goffs Falls Road
Manchester, NH 03111-00001
NEW JERSEY
Horizon Blue Cross and Blue Shield
BlueCard Claims
P.O. Box 1301
Neptune, NJ 07754-1301
NEW MEXICO
New Mexico Blue Cross and Blue Shield
Blue Cross Blue Shield of New Mexico
P. O. Box 27630
Albuquerque, New Mexico 87125
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. and is an independent licensee of the
Blue Cross and Blue Shield Association ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
NEW YORK
BlueCross and BlueShield of Central NY
Excellus BCBS
344 South Warren St
P.O. Box 4979
Syracuse, NY 13221
NEW YORK
BlueCross BlueShield of the Rochester Area
Excellus BCBS
Attn: Claims
165 Court St
Rochester, NY 14647
NEW YORK
Blue Cross and Blue Shield of Utica- Watertown
Excellus BCBS-Utica Division
Attn: Claims receivable Unit
12 Rhoads Dr.
Utica, NY 13502
NEW YORK
Empire Blue Cross and Blue Shield
BlueCard Program
P.O. Box 3877
Church Street Station
New York, NY 10008-3877
NEW YORK
Blue Cross and Blue Shield of Western NY
BlueCross BlueShield of Western New York
P.O. Box 80
Buffalo, New York 14240-0080
NEW YORK
Blue Shield of Northeastern New York
P.O. Box 80
Buffalo, New York 14240-0080
NORTH CAROLINA
Blue Cross and Blue Shield of North Carolina
Attn: BlueCard
P.O. Box 35
Durham, NC 27702
NORTH DAKOTA
BlueCross BlueShield North Dakota
4510 13th Ave S
Fargo, ND 58121-0001
OHIO
Anthem Blue Cross and Blue Shield
Anthem Document Management
P.O. Box 31780
Louisville, KY 40233
OKLAHOMA
Blue Cross and Blue Shield of Oklahoma
BCBS of Oklahoma
Attn: Document Control
P.O. Box 3283
Tulsa, OK 74102-3283
OREGON
Regence BlueCross BlueShield of Oregon
P.O. Box 30805
Salt Lake City, UT 84130-0805
PENNSYLVANIA
Blue Cross of Northeastern Pennsylvania
Attn: Michelle Holzman, Supervisor ITS Claims
19 North Main St.
Wilkes-Barre, PA 17801
PENNSYLVANIA
Capital Blue Cross
P.O. Box 779503
Harrisburg, PA 17177-9503
PENNSYLVANIA
Highmark Blue Cross and Blue Shield
Attn: Document Preparation, Claims Scanning
P.O. Box 890062
Camp Hill, PA 17089-0062
PENNSYLVANIA
Independence Blue Cross
1901 Market St.
Attn: Host ITS Area C3
Philadelphia, PA 19103
PUERTO RICO
La Cruz Azul de Puerto Rico
BlueCard Department
P.O. Box 366068
San Juan, PR 00936-6068
RHODE ISLAND
Blue Cross and Blue Shield of Rhode Island
444 Westminster St
Providence, RI 02903
Attn: Mail Support Services
SOUTH CAROLINA
Blue Cross and Blue Shield of South Carolina
P.O. Box 100300
Columbia, SC 29202
SOUTH DAKOTA
Wellmark Blue Cross and Blue Shield
636 Grand Avenue, Station 39
Des Moines, Iowa 50309
CareFirst BlueCross BlueShield is the business name of Group Hospitalization and Medical Services, Inc. and is an independent licensee of the
Blue Cross and Blue Shield Association ® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
TENNESSEE
Blue Cross and Blue Shield of Tennessee
BlueCross BlueShield of Tennessee
P.O. Box 180150
Chattanooga, TN 37402
TEXAS
Blue Cross and Blue Shield of Texas
Blue Cross Blue Shield of Texas
P.O. Box 660044
Dallas, Texas 75266-0044
U.S. VIRGIN ISLANDS
Blue Cross and Blue Shield of the
U.S. Virgin Islands
P.O. Box 8470
St Thomas, VI 00801
UTAH
Regence BlueCross BlueShield
P.O. Box 30270
Salt Lake City, UT 84130-0270
VERMONT
Blue Cross and Blue Shield of Vermont
Attn: BlueCard Department
P.O. Box 186
Montpelier VT 05601-0186
VIRGINIA
Anthem Blue Cross and Blue Shield
P.O. Box 27401
Richmond, VA 23279
WASHINGTON
Premera Blue Cross
P.O. Box 91080
Seattle, WA 98111
WASHINGTON
Regence BlueShield
P.O. Box 21267
Seattle, WA 98111
WEST VIRGINIA
Mountain State Blue Cross and Blue Shield
BlueCard Unit
Attn: Pam Uchanski
45 20th Street
Wheeling, WV 26003
WISCONSIN
Blue Cross Blue Shield of Wisconsin
P.O. Box 2270
Fond du Lac, WI 54936-2270
WYOMING
Blue Cross and Blue Shield of Wyoming
Attn: Sherry Fierro
P.O. Box 2266
Cheyenne, WY 82003

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