Commercial Member Claim printable pdf download

COMMERCIAL MEMBER CLAIM

This form may be used for Health Net and Health Net Life Insurance Company products or products offered by your employer group.

Complete the claim form as indicated below. For your protection, California law requires the following to appear on this form: Any person

who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement

in state prison. Fill out a separate form for each member submitting bills for covered services. To avoid any delay be sure to answer

STEP 1.

each question completely. ASK YOUR PHYSICIAN TO COMPLETE THE BACK OF THIS FORM.

SUBMIT TO:

HEALTH NET COMMERCIAL CLAIMS

P.O. BOX 14702

LEXINGTON, KY 40512

PLEASE ATTACH FULLY ITEMIZED BILLS AND / OR PROOF OF PAYMENT.

SUBSCRIBER INFORMATION - Employee Social Security # must be indicated to assure prompt processing of this request.

SUBSCRIBER NAME

LAST

FIRST

SUBSCRIBER SOCIAL SECURITY #

HOME ADDRESS

DATE OF BIRTH (Mo / Day / Yr)

GROUP #

❑

CITY

STATE

ZIP

IS THIS A NEW ADDRESS?

MARITAL STATUS

Married

Single

❑

Yes

Divorced

Widowed

PATIENT INFORMATION

CLAIM IS FOR

IF SON / DAUGHTER, IS HE OR SHE MARRIED?

❑

Self

Spouse

Daughter

Son

Other (specify) _______________

Yes

SPOUSE / DEPENDENT INFORMATION - Complete below if claim is for employee’s spouse or dependent.

NAME

LAST

FIRST

DATE OF BIRTH

❑

Is your child dependent upon you for at least half of his or her maintenance and support? .........................................................

Yes

❑

Is he or she a full-time student? ....................................................................................................................................................

Yes

IF DEPENDENT IS A STUDENT, GIVE NAME AND LOCATION OF HIS OR HER SCHOOL

NUMBER OF UNITS

❑

Did you obtain services from a Health Net network physician?

Yes

❑

Yes

Approx Date ______________

HAVE YOU OR YOUR PHYSICIAN RECEIVED PRECERTIFICATION FOR ALL OR PART OF THE CLAIM?

ILLNESS / INJURY / PREGNANCY INFORMATION

NAME OF REFERRING PHYSICIAN

DID YOU SELECT THIS PHYSICIAN FROM YOUR NETWORK DIRECTORY?

(FOR SELECT, OPTION OR ELECT)

❑

Yes

❑

IS THIS PHYSICIAN AFFILIATED WITH YOUR PMG / IPA?

IS THE INJURY OR ILLNESS WORK RELATED?

Yes

(FOR SELECT, OPTION OR ELECT)

❑

If yes, employer’s name

Yes

DATE ACCIDENT OR ILLNESS OCCURRED

DO YOU BELIEVE YOU ARE COVERED BY OTHER MEDICAL INSURANCE PREVIOUS TO HEALTH NET FOR THIS CONDITION?

❑

No If yes, give name(s)

Yes

OTHER HEALTH INSURANCE INFORMATION

IS PATIENT PRESENTLY COVERED BY OTHER MEDICAL INSURANCE, INCLUDING MEDICARE?

FOR MEDICARE, INDICATE PARTS MEMBER IS ENROLLED IN

❑

Yes

Part A

Part B

NAME OF OTHER INSURANCE COMPANY

POLICY #

EFFECTIVE DATE

INSURANCE COMPANY ADDRESS

CITY

STATE

ZIP

NAME OF INSURED POLICYHOLDER

SOCIAL SECURITY #

DATE OF BIRTH

EMPLOYER NAME

EMPLOYER ADDRESS

CITY

STATE

ZIP

AUTHORIZATION TO OBTAIN AND RELEASE MEDICAL INFORMATION

I hereby authorize any physician, health care practitioner, hospital, clinic or other medically related facility to furnish to Health Net, its agents, designees or representatives,

any and all information pertaining to medical treatment for purposes of reviewing, investigating or evaluating applications or claims. I also authorize Health Net, its agents,

designees or representatives to disclose to a hospital or health care service plan, insurer or self-insurer any such medical information obtained if such disclosure is necessary

to allow the processing of any claim.

If my coverage is under a Group Benefit Agreement held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them

to the extent necessary for utilization review or financial audit purposes.

This authorization shall become effective immediately and shall remain in effect as long as Health Net is asked to process claims under my coverage.

A photostatic copy of this authorization shall be considered as effective and valid as the original.

I hereby certify that the above statements are correct.

SIGNATURE OF EMPLOYEE

NAME OF PERSON PREPARING FORM (Please print)

DATE

13414 (11/02)

(Physician Statement on Reverse)