"Medical Claim Form - Harvard Pilgrim Health Care"

ADVERTISEMENT
ADVERTISEMENT

Download "Medical Claim Form - Harvard Pilgrim Health Care"

404 times
Rate (4.6 / 5) 24 votes
Harvard Pilgrim Health Care
P.O. Box 699183
Quincy, MA 02269
CLAIM FORM
1-888-333-4742
TO THE MEMBER
1.
Please read and complete this side of the claim form.
2.
Please ask your provider to read and complete the back side of the claim form or they may
attach a complete and itemized bill.
3.
PLEASE SIGN ONLY ONE OF THE “ASSIGNMENT OF BENEFITS” BOXES.
4.
In states other than Massachusetts and Maine, Allianz Life is the Underwriter of out-of-net-
work benefits for fully insured accounts.
SUBSCRIBER NAME
FIRST
INITIAL
LAST
ADDRESS (STREET AND NO.)
CITY
STATE
ZIP
PATIENT’S NAME
FIRST
INITIAL
LAST
MEMBER IDENTIFICATION NO. (FROM I.D. CARD)
DATE OF BIRTH
SEX
M o
___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___
/
/
F o
IS THE CONDITION REQUIRING
o YES
o YES
AUTO ACCIDENT
INJURY
o YES
o NO
o NO
TREATMENT RELATED TO:
EMPLOYMENT
o NO
DATE OF ILLNESS
MONTH
DAY
YEAR
HOW AND WHERE DID ACCIDENT OCCUR?
OR ACCIDENT
/
/
o YES
IS THE SUBSCRIBER’S
IF YES, NAME OF COMPANY
o NO
SPOUSE EMPLOYED?
o YES
IS PATIENT COVERED BY
IF YES, NAME OF OTHER INSURANCE
ID NUMBER
o NO
OTHER HEALTH INSURANCE?
o YES
IS PATIENT COVERED BY
IF YES, NAME OF OTHER INSURANCE
ID NUMBER
o NO
OTHER DENTAL INSURANCE?
I hereby apply for benefits and certify that the above information is complete, true and correct. To all physicians and other medical
professionals, hospitals, and other medical care institutions, and to insurers, medical or hospital service and prepaid health plans,
employers and group policy holders, contract holders or benefit plan administrators: You are authorized to provide the Plan and any
benefit plan administrators from consumer reporting agencies, attorneys and independent claim administrators acting on the Plan’s
behalf, with information concerning medical care, advice, treatment or supplies provided to the Patient, and any employment related
information regarding the Patient. This information will be used for the purpose of evaluating and administering claims for benefits.
I understand that the duration of the authorization is for the term of coverage of the policy or contract under which a claim for health
benefits has been submitted. I understand that I have a right to receive a copy of this authorization upon request. I agree that a
photographic copy of this authorization is as valid as the original.
CLAIM CANNOT BE PROCESSED WITHOUT MEMBER’S SIGNATURE.
SUBSCRIBER’S SIGNATURE
DATE
DEPENDENT PATIENT’S SIGNATURE
DATE
IF NOT A MINOR
Harvard Pilgrim Health Care
P.O. Box 699183
Quincy, MA 02269
CLAIM FORM
1-888-333-4742
TO THE MEMBER
1.
Please read and complete this side of the claim form.
2.
Please ask your provider to read and complete the back side of the claim form or they may
attach a complete and itemized bill.
3.
PLEASE SIGN ONLY ONE OF THE “ASSIGNMENT OF BENEFITS” BOXES.
4.
In states other than Massachusetts and Maine, Allianz Life is the Underwriter of out-of-net-
work benefits for fully insured accounts.
SUBSCRIBER NAME
FIRST
INITIAL
LAST
ADDRESS (STREET AND NO.)
CITY
STATE
ZIP
PATIENT’S NAME
FIRST
INITIAL
LAST
MEMBER IDENTIFICATION NO. (FROM I.D. CARD)
DATE OF BIRTH
SEX
M o
___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___
/
/
F o
IS THE CONDITION REQUIRING
o YES
o YES
AUTO ACCIDENT
INJURY
o YES
o NO
o NO
TREATMENT RELATED TO:
EMPLOYMENT
o NO
DATE OF ILLNESS
MONTH
DAY
YEAR
HOW AND WHERE DID ACCIDENT OCCUR?
OR ACCIDENT
/
/
o YES
IS THE SUBSCRIBER’S
IF YES, NAME OF COMPANY
o NO
SPOUSE EMPLOYED?
o YES
IS PATIENT COVERED BY
IF YES, NAME OF OTHER INSURANCE
ID NUMBER
o NO
OTHER HEALTH INSURANCE?
o YES
IS PATIENT COVERED BY
IF YES, NAME OF OTHER INSURANCE
ID NUMBER
o NO
OTHER DENTAL INSURANCE?
I hereby apply for benefits and certify that the above information is complete, true and correct. To all physicians and other medical
professionals, hospitals, and other medical care institutions, and to insurers, medical or hospital service and prepaid health plans,
employers and group policy holders, contract holders or benefit plan administrators: You are authorized to provide the Plan and any
benefit plan administrators from consumer reporting agencies, attorneys and independent claim administrators acting on the Plan’s
behalf, with information concerning medical care, advice, treatment or supplies provided to the Patient, and any employment related
information regarding the Patient. This information will be used for the purpose of evaluating and administering claims for benefits.
I understand that the duration of the authorization is for the term of coverage of the policy or contract under which a claim for health
benefits has been submitted. I understand that I have a right to receive a copy of this authorization upon request. I agree that a
photographic copy of this authorization is as valid as the original.
CLAIM CANNOT BE PROCESSED WITHOUT MEMBER’S SIGNATURE.
SUBSCRIBER’S SIGNATURE
DATE
DEPENDENT PATIENT’S SIGNATURE
DATE
IF NOT A MINOR
ASSIGNMENT OF BENEFITS
PAYMENT WILL BE MADE DIRECTLY TO THE PROVIDER, IF YOU SIGN BELOW.
I AUTHORIZE PAYMENT OF BENEFITS TO THE PHYSICIAN OR PROVIDER DESCRIBED BELOW OR AS INDICATED ON THE ENCLOSED BILL. I UNDER-
STAND THAT I AM FINACIALLY RESPONSIBLE TO THE PROVIDER FOR CHARGES IN EXCESS OF THE PLAN’S PAYMENT SCHEDULE OR CHARGES NOT
COVERED BY MY BENEFIT PLAN.
SIGNED (SUBSCRIBER)
DATE
OR
PAYMENT WILL BE MADE DIRECTLY TO YOU, IF YOU SIGN BELOW.
I AUTHORIZE REIMBURSEMENT OF BENEFITS TO MYSELF FOR SERVICES DESCRIBED BELOW OR AS INDICATED ON THE ENCLOSED BILL. I UNDER-
STAND THAT I AM FINANCIALLY RESPONSIBLE TO THE PROVIDER FOR CHARGES IN EXCESS OF THE PLAN’S PAYMENT SCHEDULE OR CHARGES
NOT COVERED BY MY BENEFIT PLAN.
SIGNED (SUBSCRIBER)
DATE
PLEASE NOTE:
PAYMENT FOR SERVICES RENDERED BY CONTRACTED/IN-NETWORK PROVIDERS WILL BE MADE TO THE PHYSICIAN OR PROVIDER OF SERVICE.
TO THE HOSPITAL –
ATTACH FULLY COMPLETED UB-92 BILLING FORM.
OR
ATTACH FULLY ITEMIZED STATEMENT OF CHARGES AND CREDITS.
PHYSICIAN’S/SURGEON’S STATEMENT
– COMPLETE FOLLOWING OR ATTACH FULLY COMPLETED HCFA 1500 FORM
PATIENT’S NAME:
FIRST
INITIAL
LAST
DATE OF BIRTH
DATE OF
ILLNESS (FIRST SYMPTOM) OR
DATE FIRST CONSULTED YOU
HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?
INJURY (ACCIDENT) OR
FOR THIS CONDITION
o
o
YES
NO
PREGNANCY (LMP)
DATE PATIENT ABLE TO RETURN
DATES OF TOTAL DISABILITY
DATES OF PARTIAL DISABILITY
TO WORK
FROM
THROUGH
FROM
THROUGH
NAME OF REFERRING PHYSICIAN OR OTHER SOUCE (e.g. public health agency)
FOR SERVICES RELATED TO HOSPITALIZATION
GIVE HOSPITALIZATION DATES
ADMITTED
DISCHARGED
NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (if other than home or office)
WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE?
o
o
NO
YES
CHARGES
DIAGNOSIS AND CONCURRENT CONDITIONS
SECONDARY
ICD9-CM CODE
PRIMARY
ICD9-CM CODE
PLACE OF SERVICE (POS)
• 1 – Inpatient Hospital
• 4 – Patient’s Home
• 7 – Nursing Home
• 10 – Other Locations
• 13 – Hospital Emergency Room
• 2 – Outpatient Hospital
• 5 – Day Care Facility
• 8 – Skilled Nursing Facility
• 11 – Independent Laboratory
• 3 – Doctor’s Office
• 6 – Night Care Facility
• 9 – Ambulance
• 12 –
Other Medical/Surgical Facility
SERVICES RENDERED
No.
DO NOT USE
DESCRIBE EACH SERVICE
PROCEDURE
AMOUNT
THESE SPACES
OF
POS.
SEPARATELY
NUMBER
BILLED
FROM
TO
SVCS.
A
AA
O
R
YOUR SOCIAL SECURITY NO.
TOTAL CHARGE
AMOUNT PAID
BALANCE DUE
SIGNATURE OF PHYSICIAN OR SUPPLIER
SIGNED ________________________________ DATE ____________
PHYSICIAN’S OR SUPPLIER’S NAME, ADDRESS, ZIP
YOUR EMPLOYER I.D. NO.
YOUR PATIENT’S ACCOUNT NO.
CODE & TELEPHONE NO.
I.D. NO.
AUTHORIZATIONS TO ASSIGN BENEFITS WILL NOT BE HONORED UNLESS YOUR TAX IDENTIFICATION OR SOCIAL SECURITY NUMBER IS SHOWN.
*PLACE OF SERVICE CODES
4 – (H) – PATIENT’S HOME
7 – (NH) – NURSING HOME
O – (OL) – OTHER LOCATIONS
1 – (IH) – INPATIENT HOSPITAL
5 –
DAY CARE FACILITY (PSY)
8 – (SNF) – SKILLED NURSING FACILITY
A – (IL) – INDEPENDENT LABORATORY
2 – (OH) – OUTPATIENT HOSPITAL
6 –
NIGHT CARE FACILTY (PSY)
9 –
AMBULANCE
B –
OTHER MEDICAL/SURGICAL
3 – (O) – DOCTOR’S OFFICE
FACILITY
cc1840_ppo
12_13
Page of 2