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excellus_medical_claim_form Rochester SECURE 1
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  • Title: excellus_medical_claim_form
  • Type: Notes
  • School: Rochester
  • Course: SECURE 1
  • Term: Fall

Coursehero >> New York >> Rochester >> SECURE 1
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Court 165 Street Rochester, NY 14647 A nonprofit independent licensee of the BlueCross BlueShield Association University of Rochester Mail Completed Claims To: Excellus BlueCross BlueShield PO Box 22999 Rochester, NY 14692 Subscriber identification number (including ID prefix): Subscriber Claim Form Subscriber's Full Name Address City, State, Zip Code 2 1. Patient Information: Patient's full name: Sex: Male Female Relationship to subscriber: 1. Self 3. Child 2. Spouse 4. College Student If treatment was the result of a non-work injury, give date of injury: Patient's date of birth: If other than USA, in what country was patient treated? Patient diagnosis (illness/injury which required treatment): 2. Check if you want payment to be made directly to the provider . . . .. 3. Medicare: (Nonparticipating providers within the Rochester service area are not eligible.) Regardless of age, if the patient is covered by Medicare, please be sure to send bills and matching "Explanation of Medicare Benefit". 4. Motor Vehicle or Work Related Illness or Injury: a. Was the treatment in any way motor vehicle related? . . . . . . . . . . . . . . . . . . . . . . . . . b. Was the treatment the result of a work related illness or injury? . . . . . . . . . . . . . . . . . . . . c. If answer to a. or b. is yes, please describe accident or illness: Check If: YES YES NO NO Date of accident or illness: I have other Insurance. My other Insurance has changed. If we are your secondary insurance, please be sure to send 5. Other Insurance Carrier: itemized bill and matching Explanation of Benefit form(s) from If the patient is covered by another health care plan: Policyholder's name: Name of policyholder's employer: Name and address of insurance carrier: Policy or certificate number: Date of birth: the other insurance company. Social Security number: Relationship to patient: Employment status: Retired Active This policy covers the: Individual Husband & Wife Parent & Child Family Effective/Cancellation date: Carrier's telephone number: Spouse's date of birth: 6. Claim Date and Subscriber Signature: (Unsigned claims will be returned.) Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals information concerning any fact material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 the and stated value of the claim for each violation. In addition, I hereby authorize any insurance company, organization, employer, hospital, doctor or any other provider of service to release any information requested relevant to this claim and any attached bills. Date: Subscriber's signature: MSA-13 How To Submit Your Claim This claim form can be used to submit all your bills. However, a separate claim form must be completed for each person's bills. If you need additional claim forms, please call the EXPRESSLINE at 585-454-5010 or 1-800-548-6428. If you have any questions about completing the claim form or benefits covered under your contract, please contact us at the number listed on your identification card. Mail completed claims to: Excellus BlueCross BlueShield PO Box 22999 Rochester, NY 14692 In order to process your claim promptly, please refer to the following guidelines to ensure that all necessary information is included: A. Submit bills for each patient on separate claim forms. A separate claim form is also required for different calendar years. Please submit the original bills with your claim form. Keep copies for your own records. The actual bills are necessary for claims processing. B. Bills must include: Name and address (on letterhead) of the provider of service or supply (hospital, doctor, pharmacy, etc.). Patient's full name. Type of service or supply (office visits, chest x-ray, etc.). Place of service (inpatient or outpatient hospital, office, etc.). Date and charge for each service or supply provided. Patient's diagnosis (the medical condition for which the patient was treated). C. Bills for the following services should also include: FOR THOSE CONTRACTS WITH PRESCRIPTION DRUG COVERAGE - Prescription number, name of drug, and name of prescribing doctor is required. Durable Medical Equipment (wheelchair, oxygen tank, etc.) - A statement of medical necessity from the prescribing doctor which indicates how long the equipment will be used and a statement from the equipment supplier showing both the rental and purchase price. D. Cash register receipts, canceled checks, money orders, credit card vouchers and personal lists of services or bills stating only 'balance forward' are not acceptable as substitutes for bills. Our employees are dedicated to prompt and accurate claim payments to our subscribers. By following these instructions and filling out the claim form completely, you will help us meet our goal of processing your claim in a satisfactory manner.

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