Fillable Form Msa-1 - Medical Benefits Subscriber Claim Form printable pdf download

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A nonprofit independent licensee of the BlueCross BlueShield Association

MEDICAL BENEFITS

PLEASE REVIEW AND LEGIBLY COMPLETE ALL SECTIONS (1-5) OF THIS FORM

SUBSCRIBER CLAIM FORM

Please Note-If you do not have all of the required information, please contact the provider of service for assistance prior to submitting your

claim. Failure to supply all of the required information may result in delayed processing and/or subsequent return or denial of your claim

Mail completed form and all required

submission.

information to:

If your address has changed or is incorrect, please call our Customer Service Department at the telephone numbers listed on your

Excellus BlueCross BlueShield

identification card.

SECTION 1

P.O. Box 22999

Rochester, NY 14692

INFORMATION REQUIRED FROM SUBSCRIBER

1a-HAVE SUBMITTED EXPENSES BEEN PAID IN FULL BY YOU?

YES

Please Note-If a participating provider rendered the service(s) being submitted, payment will be made directly to the provider.

1b-ITEMIZED BILL(S) FOR SERVICES OR SUPPLIES MUST BE SUBMITTED WITH THIS FORM IN ORDER FOR

REIMBURSEMENT TO BE CONSIDERED. THE ITEMIZED BILL MUST CLEARLY INDICATE ALL OF THE FOLLOWING:

7-COUNTRY MUST BE INDICATED AND ALL

1-PATIENT'S FULL NAME AND DATE OF BIRTH

4-DESCRIPTION AND/OR VALID PROCEDURE

INFORMATION TRANSLATED TO ENGLISH FOR

CODE FOR EACH SERVICE RENDERED

2-NAME AND ADDRESS OF THE PROVIDER OF

ANY SERVICE(S) NOT RENDERED IN THE USA

5-CHARGE FOR EACH SERVICE RENDERED

SERVICE ON THEIR OFFICE LETTERHEAD,

INCLUDING PROVIDER ID NUMBER AND

8-PRESCRIPTION NUMBER AND NAME OF

6-DESCRIPTION OF ILLNESS/INJURY AND/OR

CREDENTIALS

PRESCRIBING PHYSICIAN MUST BE INDICATED

VALID DIAGNOSIS CODE FOR EACH

ON RX/MEDICINE BILLS

3-DATE FOR EACH SERVICE RENDERED

SERVICE RENDERED

SECTION 2

Please enter all information exactly

SUBSCRIBER /PATIENT INFORMATION

as shown on your ID card

2a-SUBSCRIBER'S LAST NAME

2b-FIRST NAME

2c-INITIAL 2d-SUBSCRIBER IDENTIFICATION NUMBER (Including Prefix)

2e-ADDRESS-NUMBER AND STREET

2f-CITY

2g-STATE

2h-ZIP CODE

2i-PATIENT'S LAST NAME

2k-INITIAL 2L-DATE OF BIRTH

2m-GENDER

2n-PATIENT'S RELATIONSHIP

2j-FIRST NAME

TO SUBSCRIBER

SELF

CHILD

______/______/_______

yyyy

SPOUSE

SECTION 3

OTHER HEALTH INSURANCE INFORMATION

YES

3a-IS THE PATIENT COVERED BY ANOTHER HEALTH INSURANCE PLAN (INCLUDING MEDICARE)?

please complete 3b-3g below

If YES,

3b-NAME OF OTHER POLICYHOLDER

3c-POLICY OR IDENTIFICATION NUMBER

3d-POLICY EFFECTIVE DATE:

3f-POLICYHOLDER'S DATE OF BIRTH:

3e-TYPE OF POLICY/COVERAGE:

_______/_______/__________

TWO-PERSON

FAMILY

NDIVIDUAL

yyyy

3g-NAME AND ADDRESS OF OTHER INSURANCE CARRIER

Please Note-If the patient has other primary insurance, the Explanation of Benefits form(s) from the other health insurance plan must accompany this

claim form, along with the matching itemized bill.

SECTION 4

MOTOR VEHICLE/WORK-RELATED INFORMATION

4a-ARE THE SUBMITTED EXPENSES RELATED, IN ANY WAY, TO A MOTOR VEHICLE OR WORK-RELATED ACCIDENT OR INJURY?

YES

please complete 4b & 4c below

If YES,

4b-TYPE OF ACCIDENT:

WORK

4c-DATE OF ACCIDENT OR INJURY:

MOTOR VEHICLE

OTHER

_______/_______/__________

yyyy

SECTION 5

SIGNATURE AND DATE

I CERTIFY THAT THE INFORMATION SUBMITTED IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE THE RELEASE OF ANY RELEVANT

INFORMATION TO MY INSURANCE CARRIER.

DATE:

SUBSCRIBER SIGNATURE:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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 and the stated value of each violation.

MSA-1, Rev 4/09

Form Msa-1 - Medical Benefits Subscriber Claim Form

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