Form 18-059-N35 International Claim Form - Bluecross Blueshield

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International Claim Form
Please see the instructions on the reverse side of this form before completing.
Blue Cross and Blue Shield Companies
Send completed form and documentation to:
Service Center
or
claims@bcbsglobalcore.com
are independent licensees of the Blue
P .O. Box 2048
Cross and Blue Shield Association.
or online at www.bcbsglobalcore.com
Southeastern, PA 19399
1. Patient Information
1
Member ID
Include all letters and numbers as shown on your Blue Cross Blue Shield identification card
A.
1B. Patient’s name
1C. Patient’s date of birth
1D. Patient’s sex
(First, middle initial, last)
Male
Female
MM/DD/YYYY
1E. Name of subscriber
1F. Subscriber’s date of birth
1G. Patient’s relationship
(First, middle initial, last)
to subscriber
Self
Spouse
Child
MM/DD/YYYY
1H. Subscriber’s current mailing address
1I. Patient’s e-mail address
(Street, city, state, and country or ZIP code)
2. Other Health Insurance
Is the patient covered under other health insurance, including Medicare A or B?
Yes
No
If yes, complete 2A through 2K below.
2
Name and address of other insuring company
A.
2
Type of policy
2
Effective date
2D. Termination date
2E. Policy or identification number
B.
C.
of other coverage
Family
Individual
MM/DD/YYYY
MM/DD/YYYY
2
Type of coverage
2
Name of subscriber
2
Date of birth
F.
G.
H.
Hospital:
Yes
No
Medical:
Yes
No
Mental illness:
Yes
No
MM/DD/YYYY
2
Employer of subscriber
2
Employment status
I.
J.
Active employee
Retired employee
2
If patient is covered under Medicare, complete the following:
Medicare Part A:
Yes
No
Medicare Part B:
Yes
No
K.
Effective date ________________ Effective date _________________
3. Diagnosis
3
Describe illness, injury, or symptoms requiring treatment and onset date of symptoms or injury.
A.
3
Was patient’s treatment due to a work-related accident or condition?
Yes
No
B.
3
Complete for care related to accidental injuries
C.
Date of accident _____________________________________ Location:
At home
Auto
Other ____________________________
Time of accident ____________________________________
If the accident was caused by someone else, attach a statement describing the accident.
4. Charges
— Use a separate line to list each type of service or provider and attach itemized bills for all services.
4A. Name and address of
4B. Type of provider
4C. Description of service
4D. Dates of service
4E. Charges
or purchase
provider making charge
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5. Payee
— Select one of the following payment options:
Option
Make payment to subscriber; provider has been paid.
A.
Select your payment preference:
Check – US Dollar
Electronic Funds Transfer – US Dollar
Electronic Funds Transfer – Currency on itemized bill(s)
If you want to receive an electronic funds transfer provide the following:
Subscriber name as it appears on bank account: _____________________________________________________ Bank name: _____________________________________________
Bank’s Physical Address: _____________________________________________________________________________________________________________________________________
Account # /IBAN: ________________________________________________________________________Routing # / ABA / BIC / SWIFT: _______________________________________
Option
Make payment to provider (hospital, doctor), if appropriate. Please complete and sign to authorize direct payment to provider.
B.
I, the undersigned, authorize and request payment for benefits due herein to be made to the following provider of services, if such direct payment is deemed appropriate
by the subscriber’s Blue Cross and Blue Shield company:
Name of provider _______________________________________ Signature of subscriber or spouse ________________________________________________ Date _________________
6. Signature
I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization
is hereby given to any provider of service, that participated in any way in the patient's care, to release to the subscriber's Blue Cross and Blue Shield company and its
business associates in any country any medical or other personal information that they deem necessary to provide service or adjudicate this claim, recognizing that
applicable law concerning personal information may differ among countries. Authorization is also given to the subscriber's Blue Cross and Blue Shield company and
its business associates in any country to collect, use or release any medical or other personal information that they deem necessary to provide service, adjudicate a
claim or as otherwise described in such Blue Cross and Blue Shield company’s Notice of Privacy Practices.
Signature of subscriber or patient
________________________________________________________________________________________ Date _________________________
International Claim Form
Please see the instructions on the reverse side of this form before completing.
Blue Cross and Blue Shield Companies
Send completed form and documentation to:
Service Center
or
claims@bcbsglobalcore.com
are independent licensees of the Blue
P .O. Box 2048
Cross and Blue Shield Association.
or online at www.bcbsglobalcore.com
Southeastern, PA 19399
1. Patient Information
1
Member ID
Include all letters and numbers as shown on your Blue Cross Blue Shield identification card
A.
1B. Patient’s name
1C. Patient’s date of birth
1D. Patient’s sex
(First, middle initial, last)
Male
Female
MM/DD/YYYY
1E. Name of subscriber
1F. Subscriber’s date of birth
1G. Patient’s relationship
(First, middle initial, last)
to subscriber
Self
Spouse
Child
MM/DD/YYYY
1H. Subscriber’s current mailing address
1I. Patient’s e-mail address
(Street, city, state, and country or ZIP code)
2. Other Health Insurance
Is the patient covered under other health insurance, including Medicare A or B?
Yes
No
If yes, complete 2A through 2K below.
2
Name and address of other insuring company
A.
2
Type of policy
2
Effective date
2D. Termination date
2E. Policy or identification number
B.
C.
of other coverage
Family
Individual
MM/DD/YYYY
MM/DD/YYYY
2
Type of coverage
2
Name of subscriber
2
Date of birth
F.
G.
H.
Hospital:
Yes
No
Medical:
Yes
No
Mental illness:
Yes
No
MM/DD/YYYY
2
Employer of subscriber
2
Employment status
I.
J.
Active employee
Retired employee
2
If patient is covered under Medicare, complete the following:
Medicare Part A:
Yes
No
Medicare Part B:
Yes
No
K.
Effective date ________________ Effective date _________________
3. Diagnosis
3
Describe illness, injury, or symptoms requiring treatment and onset date of symptoms or injury.
A.
3
Was patient’s treatment due to a work-related accident or condition?
Yes
No
B.
3
Complete for care related to accidental injuries
C.
Date of accident _____________________________________ Location:
At home
Auto
Other ____________________________
Time of accident ____________________________________
If the accident was caused by someone else, attach a statement describing the accident.
4. Charges
— Use a separate line to list each type of service or provider and attach itemized bills for all services.
4A. Name and address of
4B. Type of provider
4C. Description of service
4D. Dates of service
4E. Charges
or purchase
provider making charge
....................................................................................................................................
..............................................................................
...............................................................................................................................
..........................................................................
.................................................
....................................................................................................................................
..............................................................................
...............................................................................................................................
..........................................................................
.................................................
....................................................................................................................................
..............................................................................
...............................................................................................................................
..........................................................................
.................................................
....................................................................................................................................
..............................................................................
...............................................................................................................................
..........................................................................
.................................................
5. Payee
— Select one of the following payment options:
Option
Make payment to subscriber; provider has been paid.
A.
Select your payment preference:
Check – US Dollar
Electronic Funds Transfer – US Dollar
Electronic Funds Transfer – Currency on itemized bill(s)
If you want to receive an electronic funds transfer provide the following:
Subscriber name as it appears on bank account: _____________________________________________________ Bank name: _____________________________________________
Bank’s Physical Address: _____________________________________________________________________________________________________________________________________
Account # /IBAN: ________________________________________________________________________Routing # / ABA / BIC / SWIFT: _______________________________________
Option
Make payment to provider (hospital, doctor), if appropriate. Please complete and sign to authorize direct payment to provider.
B.
I, the undersigned, authorize and request payment for benefits due herein to be made to the following provider of services, if such direct payment is deemed appropriate
by the subscriber’s Blue Cross and Blue Shield company:
Name of provider _______________________________________ Signature of subscriber or spouse ________________________________________________ Date _________________
6. Signature
I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above. Authorization
is hereby given to any provider of service, that participated in any way in the patient's care, to release to the subscriber's Blue Cross and Blue Shield company and its
business associates in any country any medical or other personal information that they deem necessary to provide service or adjudicate this claim, recognizing that
applicable law concerning personal information may differ among countries. Authorization is also given to the subscriber's Blue Cross and Blue Shield company and
its business associates in any country to collect, use or release any medical or other personal information that they deem necessary to provide service, adjudicate a
claim or as otherwise described in such Blue Cross and Blue Shield company’s Notice of Privacy Practices.
Signature of subscriber or patient
________________________________________________________________________________________ Date _________________________
General Information
• The Blue Cross Blue Shield Global
®
Core International Claim Form is to be used to submit institutional and professional claims for
benefits for covered services received outside the United States, Puerto Rico and the U.S. Virgin Islands.
• For other claim types (e.g., dental, prescription drugs), contact your Blue Cross and Blue Shield Company for filing instructions.
• Please complete all fields. If the information requested does not apply to the patient, indicate N/A (Not Applicable).
• Please attach receipts and medical records (test results, x-rays, etc.), if available.
• Please keep photocopies of all documentation for your personal records.
Itemized Bill Information
Each provider’s original itemized bill must be attached and must contain:
– The letterhead indicating the name and address of the person or organization providing the service
– The full name of the patient receiving the service
– The date of each service
– A description of each service
– The charge for each service in local currency
SPECIAL CARE SHOULD BE TAKEN WHEN COMPLETING THE FOLLOWING FIELDS:
1. Patient Information
1E. Name of subscriber – For check payments, provide your full name (initials are not acceptable).
1H. Subscriber’s current mailing address – If check payment is requested, this address will be used. Please provide your physical address
(payments cannot be sent to a P .O. Box).
2. Other Health Insurance
If the patient holds other insurance coverage, please complete items A through K as completely as possible. It is especially important to
indicate the name and address of the other insurance company and the policy or identification number of that coverage, as well as the name
and birth date of the person who holds that policy.
In addition, if the patient is someone other than the subscriber and has received benefits from any other health insurance plan held by reason
of law or employment, the Explanation of Benefits Form furnished by the other carrier pertaining to these charges must be included with the
claim. A clear photocopy of the other carrier’s Explanation of Benefits Form is acceptable in place of the original document.
4. Charges
Please list the attached bills. Although itemized bills from the provider showing a separate charge for each service must be submitted,
your listing will enable us to process the claim more quickly. If additional space is needed, please use a separate sheet of paper to list the
following information:
4A. Name and Address of provider — as indicated on the bill. Multiple bills from the same provider may be included on the same line,
as long as they are for the same type of service.
4B. Type of provider — for example: hospital, nurse, physician, clinic, physical therapist, etc.
4C. Description of service — for example: hospital admission, office visit, x-ray, laboratory test, surgery, etc.
4D. Date of service or purchase — inclusive dates may be indicated for bills containing multiple dates of service.
4E. Charge —as indicated on the bill. If the bill has already been paid, please indicate the date it was paid.
5. Payee
Option A. Make payment to subscriber, designation of currency and payment method — Please note that not all forms of currency may
be available for payment. In the event that you select payment in a currency that is not available, you will be paid in U.S. dollars.
Banks may charge a fee to receive a wire. You may want to research fees charged by your bank prior to requesting a wire since
you will be responsible for any such fees.
For an electronic funds transfer, provide the bank’s physical address where the account was opened (not a P .O. Box). Please provide a copy of a
voided check or deposit slip so that the bank information can be validated.
Option B. Authorization for payment to provider — complete option B if you prefer that benefits be paid directly to the provider of service.
Direct payment to the provider is at the discretion of your Blue Cross and Blue Shield Company, except where required by law.
6. Signature
The International Claim Form must be signed and dated by the subscriber, spouse, or the patient.
Disclosure Statement
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
18-059-N35

Download Form 18-059-N35 International Claim Form - Bluecross Blueshield

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