Customer Claim Form - Highmark Blue Cross Blue Shield Delaware

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Mail completed forms and receipts to:
Highmark Blue Cross Blue Shield Delaware
CUSTOMER CLAIM FORM
P.O. Box 8831
Please read instructions on reverse side.
Wilmington, DE 19899-8831
BENEFITS WILL BE ADMINISTERED IN ACCORDANCE WITH THE TERMS OF YOUR BENEFIT PLAN. (Please complete form using black or blue ink.)
1. CUSTOMER’S NAME
2. If you, your spouse, or dependent children insured under this benefits plan
are also covered under any other health insurance plan, please indicate:
Last
First
M.I.
Name of Insured Person
q Check box for change of address
CUSTOMER’S ADDRESS
Policy Number
Street
Name of Health Insurance Company
Address of Health Insurance Company
City
State
Zip Code
4. Was the treatment required as a result of an accident or injury?
Area Code
Telephone Number
q Yes
q No
How and where did the incident happen?
3. PATIENT’S NAME
Last
First
M.I.
Date of incident (month, day, year)
_______/_______/_______
PATIENT’S SEX
PATIENT’S RELATIONSHIP TO INSURED
q Male
q Female
q Self
q Spouse
q Child
5. Medical condition (diagnosis) or symptoms requiring treatment:
PATIENT’S DATE OF BIRTH
ACCOUNT NUMBER
_______/_______/_______
IDENTIFICATION NUMBER-
Include any letters
6.
Check category(ies) for which you are submitting receipts and list total charges:
q
Physician Home and Office Visits: For charges from physicians, please submit on the physician’s letterhead or billing form.
This must include:
$____________
Patient’s name
Date of service
Diagnosis code and symptoms
l
l
l
Charge for each service
Service code (CPT or HCPCS) and description of service
l
l
q
Prescription Drugs: For charges from a pharmacy, statements must include:
$____________
Patient’s name
Prescribing physician
Name of drug
l
l
l
Dispensing date
Charge for prescription
l
l
q
Certain Over-The-Counter Drugs: Please refer to instructions on reverse for further details on items to include when submitting this form.
$____________
q
Appliances and Durable Medical Equipment: For charges from a company providing these items, the statement must include:
$____________
Patient’s name
Name of equipment/appliance
Prescription from physician describing need for equipment/appliance
l
l
l
Date of purchase or rental
Charge for equipment/appliance
Service code (CPT or HCPCS)
l
l
l
q
Mental Health Services (out-of-hospital): For charges from psychiatrist or licensed psychologist, please submit a statement
on the provider’s letterhead or billing form. This must include:
$____________
Patient’s name
Date of service
Length of session (e.g., 1/2 hr., 1 hr.)
l
l
l
Charge for each service
Treating physician
Service code (CPT or HCPCS) and description of service
$____________
l
l
l
Diagnosis or symptoms
l
q
Private Duty Professional Nursing (in-hospital only): For charges from a professional nurse, please submit a statement
and a physician’s prescription certifying the necessity of the services ordered. This nurse’s statement must include:
$____________
Patient’s name
Date(s) of service
Hours and shift for each service
l
l
l
Diagnosis
Dates of admission & discharge
Nurse’s name, license number and R.N. or L.P.N. designation
l
l
l
$____________
Charge for each service
Name of hospital
Nurse’s signature
l
l
l
q
Hospital Services: Attach itemized statements and/or bills.
$____________
q
Other Services Specifically Included in Your Benefits Plan: Please refer to your benefits literature before using this section.
Statements must be on the provider’s letterhead or billing form. Attach itemized statements and/or bills.
$____________
$
TOTAL CHARGES, ALL CATEGORIES
7.
I certify that all of the information provided by me, including statements/bills listed above, is correct and complete to the best of my knowledge and that I am
claiming benefits for charges incurred by the patient named above.
Customer’s Signature:
Date: _______/_______/_______
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a claim containing any false, incomplete or misleading information may be guilty of a felony.
CLM-107 (5-12)

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