Claim Form - Blue Cross And Blue Shield Of Kansas Page 2
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4Is patient entitled to benefits from any other group health insurance?
Yes
No
If yes, complete the following:
Name of other insurance carrier
Address of other insurance carrier
Certificate or policy number
Effective Date
Cancellation Date
Name of family member in whose name the policy is carried
Name of employer of family member named above
Is this patient entitled to benefits under Medicare hospital insurance (Part A)?
Yes
No
If yes, effective date is
ID#
MM/DD/YYYY
Name on Card
Is this patient entitled to benefits under Medicare medical insurance (Part B)?
Yes
No
If yes, effective date is
ID#
MM/DD/YYYY
Name on Card
Is this patient entitled to benefits under Medicare prescription drug insurance (Part D)?
Yes
No
If yes, effective date is
ID#
MM/DD/YYYY
Name on Card
For prescription drug claims: File one claim per patient and attach an itemized bill from the pharmacy with the pharmacist’s signature
or the pharmacy receipts. Do not send cash register receipts. The proof of service must include patient’s name, prescription name and
prescription Rx number, NDC code, quantity, number of days supply, service date, cost for each prescription plus the complete name
and address of the pharmacy, and the pharmacy tax ID number.
For all other services: File one claim per patient and attach an itemized bill from the service provider. The itemization must include
the patient’s name, the service provided, service date, cost for each service, diagnosis, and the provider’s name and tax ID number.
Please complete a separate claim form in full for each hospital and/or doctor bill being submitted.
Prompt filing of claims: Notice of your claim must reach Blue Cross and Blue Shield of Kansas within one (1) year and ninety (90)
days from the date services were received. Submit this claim to:
Blue Cross and Blue Shield of Kansas
1133 SW Topeka Boulevard
Topeka, KS 66629-0001
I represent that the information on this form is correct and that I am claiming benefits only for charges incurred by the patient
named on this form.
Signature
Date
/
/
If you have questions regarding this form, call:
Blue Cross and Blue Shield of Kansas
State of Kansas Employees
(785) 291-4180
(785) 291-4185
Toll free: 1-800-432-3990
Toll free: 1-800-332-0307
To order additional forms, call Teleorder toll free at 1-800-346-2227, in Topeka at (785) 291-8130, or visit our Web site at
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