Form HLTH1915 "Medical Services Plan (Msp) Pay Practitioner Claim" - British Columbia, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form HLTH1915 "Medical Services Plan (Msp) Pay Practitioner Claim" - British Columbia, Canada

Download PDF

Fill PDF online

Rate (4.4 / 5) 12 votes
pv
medical services plan (msp)
pay practitioner claim
A B C D
claims must be submitted within 90 days. please do not fax this form.
USE CAPITAL
To ensure this claim is processed, please follow instructions on page 2.
LETTERS ONLY
patient information
PERSONAL HEALTH NUMBER (PHN)
DEPENDANT
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
CORRESPONDENCE
SUBMISSION
PATIENT BIRTHDATE (MM / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
ATTACHED
CODE
PLAN REFERENCE NUMBER OF ORIGINAL CLAIM
YES
service(s)
TIME
LOC.
DATE OF SERVICE
NO. OF
CALLED
RENDERED
OF
MONTH
DAY
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
START
FINISH
hospital visits
LOC.
DATE OF SERVICE
NO. OF
OF
MONTH
DAY FROM - TO
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
STATE TYPE OF PROCEDURE OR OPERATION
practitioner information
FIRST NAME
PRACTITIONER LAST NAME OR CLINIC NAME
INITIAL
PRACTITIONER SIGNATURE
PAYMENT NUMBER
PRACTITIONER NUMBER
SPEC. CODE
COVERAGE
PRE-AUTHORIZATION
REFERRED BY
PRACTITIONER NUMBER
REFERRED BY (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
NUMBER
REFERRED TO
PRACTITIONER NUMBER
REFERRED TO (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9689 Stn Prov Govt, Victoria BC V8W 9P8
Web: www.hibc.gov.bc.ca
Tel: (Lower Mainland) 604 456-6950, (Rest of BC) 1 866 456-6950
HLTH 1915 V3 Rev. 2012/08/16
PRINT
RESET
pv
medical services plan (msp)
pay practitioner claim
A B C D
claims must be submitted within 90 days. please do not fax this form.
USE CAPITAL
To ensure this claim is processed, please follow instructions on page 2.
LETTERS ONLY
patient information
PERSONAL HEALTH NUMBER (PHN)
DEPENDANT
PATIENT LEGAL FIRST NAME
SECOND NAME INITIAL
PATIENT LEGAL LAST NAME
CORRESPONDENCE
SUBMISSION
PATIENT BIRTHDATE (MM / YYYY)
MVA RELATED? IF YES, MVA CLAIM NUMBER
ATTACHED
CODE
PLAN REFERENCE NUMBER OF ORIGINAL CLAIM
YES
service(s)
TIME
LOC.
DATE OF SERVICE
NO. OF
CALLED
RENDERED
OF
MONTH
DAY
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
START
FINISH
hospital visits
LOC.
DATE OF SERVICE
NO. OF
OF
MONTH
DAY FROM - TO
YEAR
SERVICES
S.C.C.
FEE ITEM
AMOUNT BILLED
DIAGNOSTIC CODE
SERV.
STATE TYPE OF PROCEDURE OR OPERATION
practitioner information
FIRST NAME
PRACTITIONER LAST NAME OR CLINIC NAME
INITIAL
PRACTITIONER SIGNATURE
PAYMENT NUMBER
PRACTITIONER NUMBER
SPEC. CODE
COVERAGE
PRE-AUTHORIZATION
REFERRED BY
PRACTITIONER NUMBER
REFERRED BY (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
NUMBER
REFERRED TO
PRACTITIONER NUMBER
REFERRED TO (PRACTITIONER LAST NAME)
FIRST NAME INITIAL
Mailing Address: Health Insurance BC, Medical Services Plan, PO Box 9689 Stn Prov Govt, Victoria BC V8W 9P8
Web: www.hibc.gov.bc.ca
Tel: (Lower Mainland) 604 456-6950, (Rest of BC) 1 866 456-6950
HLTH 1915 V3 Rev. 2012/08/16
PRINT
RESET
instructions for completinG and submittinG this claim
Only the following claim types can be submitted by mail using this downloadable “fill, print and mail” Claim Form:
• Correctional facilities claims
• Dental claims
• Reciprocal claims
• Claims for patients covered under the Critical Care Coverage Program
If a practitioner can demonstrate that they reside in a community without internet access or that obtaining internet
access will cause significant financial hardship, they can submit their claims via mail using a Claim Form. To receive
paper copies of the Claims Form, practitioners must request an exemption in writing demonstrating that obtaining
internet access will cause significant hardship. Requests for an exemption should be sent to Health Insurance BC at
the address listed at the bottom of page 1. All other forms must be submitted electronically
Mail the completed form to the address that appears at the bottom of page 1 of this form.
claims must be submitted to the medical services plan (msp) within 90 days of the date of service.
patient information
In order for MSP to process this claim, the following areas must be completed:
• patient’s PERSONAL HEALTH NUMBER
• PATIENT’S LEGAL FIRST NAME, first initial of SECOND NAME (if you legally have a second name),
and LAST NAME
• PATIENT BIRTHDATE (month and year)
practitioner and services information
Please ensure that all the areas listed below are completed. Otherwise, we will be unable to process your claim.
• DATE OF SERVICE
• NO. (number) OF SERVICES
• S.C.C. (service clarification code)—if applicable
• FEE ITEM
• AMOUNT BILLED
• DIAGNOSTIC CODE
• PRACTITIONER LAST NAME OR CLINIC NAME
• PRACTITIONER SIGNATURE
• PAYMENT NUMBER
• PRACTITIONER NUMBER
Please allow 4 to 6 weeks for processing claims for routine medical services. Specialist services may require
additional processing time.
HLTH 1915 PAGE 2
Page of 2