Form 008755 "Member Submitted Claim Form - Premera Blue Cross" - Washington

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P .O. Box 91059
Member Submitted Claim Form
Seattle, WA 98111-9159
This form is to be used for medical, vision, and dental claims where you incurred expenses from a provider who did not bill the plan directly.
Do not use this form for prescription reimbursement. Please use the Prescription Drug Reimbursement Form (for primary prescription
claim submission) or the Secondary Insurance Prescription Drug Claim Form.
See instructions on other side for additional information to complete your claim.
1. Patient / Member
Prefix and ID number (see ID card)
Group number (see ID card)
Patient name (first, middle, last)
Date of birth (month/day/year)
Address
City
State
ZIP
Home phone number
Work or alternate phone number
Subscriber name (first, middle, last)
Does the patient have coverage from any other health plan?
No, skip to section 2
Yes, please attach the Explanation of Benefits (EOB) statement from the primary plan with this claim, and complete the following information.
Name of other health plan
ID number or policy number of other health plan Phone number of other health plan
NOTE: You must submit an itemized bill or your claim will be returned.
2. Claim Details
Have the charges been paid in full?
No
Yes, please attach proof of payment in full with your itemized bill.
In what setting were these services performed?
Inpatient hospital
Outpatient hospital
Office/clinic
Surgery center
Skilled nursing facility
Home
Other:
NOTE: You must submit an itemized bill or your claim will be returned.
3. International Claim
Is this claim for expenses incurred outside the U.S.A.?
No, skip to section 4
Yes, please attach an itemized bill, available medical records, and complete this section.
Name of provider
Type of provider
Country of service
City of service
Date of service
Hospital
Lab
Office
X-ray
Diagnosis (describe illness and symptoms requiring treatment)
Charges
Currency used
4. Accident / Injury
Is this claim due to an accidental injury?
Date of accident
Where did the accident occur?
No, skip to section 5
Yes, complete this section
Home
Work
School
Auto
Other:
How did the accident happen?
Description of injury
5. Signature
To be accepted, this form must be fully completed (as appropriate to the claim being submitted), signed, and have an itemized bill attached.
Mail to: Premera Blue Cross, P.O. Box 91059, Seattle, WA 98111-9159
Patient signature (or legal guardian if patient cannot legally consent to services)
Relationship to patient
Date (month/day/year)
Self
Other:
Please note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance benefits.
008755 (09-2015)
An Independent Licensee of the Blue Cross Blue Shield Association
P .O. Box 91059
Member Submitted Claim Form
Seattle, WA 98111-9159
This form is to be used for medical, vision, and dental claims where you incurred expenses from a provider who did not bill the plan directly.
Do not use this form for prescription reimbursement. Please use the Prescription Drug Reimbursement Form (for primary prescription
claim submission) or the Secondary Insurance Prescription Drug Claim Form.
See instructions on other side for additional information to complete your claim.
1. Patient / Member
Prefix and ID number (see ID card)
Group number (see ID card)
Patient name (first, middle, last)
Date of birth (month/day/year)
Address
City
State
ZIP
Home phone number
Work or alternate phone number
Subscriber name (first, middle, last)
Does the patient have coverage from any other health plan?
No, skip to section 2
Yes, please attach the Explanation of Benefits (EOB) statement from the primary plan with this claim, and complete the following information.
Name of other health plan
ID number or policy number of other health plan Phone number of other health plan
NOTE: You must submit an itemized bill or your claim will be returned.
2. Claim Details
Have the charges been paid in full?
No
Yes, please attach proof of payment in full with your itemized bill.
In what setting were these services performed?
Inpatient hospital
Outpatient hospital
Office/clinic
Surgery center
Skilled nursing facility
Home
Other:
NOTE: You must submit an itemized bill or your claim will be returned.
3. International Claim
Is this claim for expenses incurred outside the U.S.A.?
No, skip to section 4
Yes, please attach an itemized bill, available medical records, and complete this section.
Name of provider
Type of provider
Country of service
City of service
Date of service
Hospital
Lab
Office
X-ray
Diagnosis (describe illness and symptoms requiring treatment)
Charges
Currency used
4. Accident / Injury
Is this claim due to an accidental injury?
Date of accident
Where did the accident occur?
No, skip to section 5
Yes, complete this section
Home
Work
School
Auto
Other:
How did the accident happen?
Description of injury
5. Signature
To be accepted, this form must be fully completed (as appropriate to the claim being submitted), signed, and have an itemized bill attached.
Mail to: Premera Blue Cross, P.O. Box 91059, Seattle, WA 98111-9159
Patient signature (or legal guardian if patient cannot legally consent to services)
Relationship to patient
Date (month/day/year)
Self
Other:
Please note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance benefits.
008755 (09-2015)
An Independent Licensee of the Blue Cross Blue Shield Association
Instructions
A. Complete a claim form.
Most providers will bill directly for you and no claim form will be necessary. However, if you do incur
expenses from a provider who will not bill the plan directly, you will need to complete a claim form and provide an itemized bill. (See
section B for information about itemized bills.)
B. Attach the itemized bill.
Please do not highlight or modify the itemized bill as this may cause delayed processing of your claim.
The itemized bill must contain all of the following information:
• Name of the member who incurred the expense.
• Name, address, and IRS tax identification number of the provider.
• Diagnosis code (ICD-10). This information must be obtained from your provider.
• Procedure codes (CPT-4, HCPCS, ADA, or UB-04). This information must be obtained from your provider.
• Date of service and itemized charge for each service rendered.
Please note: Your claim will be returned if all of the required information listed above is not included.
C. The front of your member ID card
may not match the card pictured below. This sample card is meant to be a guide to help you
identify your prefix, identification, and group numbers. These numbers are required to complete your claim form.
1
2
1 — Prefix and Identification #
help us verify your eligibility, determine your
coverage, and process claims.
2 — Group #
identifies your plan’s benefits.
D. The back of your member ID card
provides additional information. To help ensure your claims are paid properly, encourage
physicians and other providers to copy the front and back of your card each time you visit.
You can research claim and eligibility information online. Visit our self-service website at premera.com. You may also call Customer
Service at the phone number shown on the back of your ID card.
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