Customer Claim Form - Highmark Blue Cross Blue Shield Delaware (Page 2 of 2) in pdf

INSTRUCTIONS

PLEASE READ THE FOLLOWING INSTRUCTIONS BEFORE COMPLETING THE REVERSE SIDE.

Do not wait until the end of the year to ﬁle your claims as this causes unnecessary delays in processing. Claims must be

received by no later than two years (24 months) from the time the service was rendered to be considered for payment.

Your original itemized statements/bills cannot be returned. You should keep photocopies for your own records.

When ﬁling a claim, please:

1. Answer all questions on the reverse side of this form. Missing or incomplete information may result in delayed

processing or possibly the return of your claim(s) for additional information.

2. Submit a separate claim form for each family member for whom you are making a claim.

3. Attach itemized statements and bills that have been completed by professional medical sources.

The following are not acceptable as proof for incurred charges:

a. Canceled checks

b. Cash register receipts

c. Visa/MasterCard receipts

d. Statements prepared by the person(s) submitting this claim form.

A service code is required on many statements/bills. A service code means either a CPT, HCPCS or other

medical code that describes the service.

4. If submitting a claim for reimbursement of certain over-the-counter (OTC) drugs*, please include the following

with each claim:

A valid prescription from a physician for each new OTC drug or reﬁll is required with each claim submitted. A

copy of the prescription can be submitted for up to one year from the date it was written for most OTC drugs;

however, a new, valid prescription is required for every nicotine replacement therapy claim. (Please note that

the prescription can include multiple items such as the patch and lozenges, and that all covered items in the

prescription will be reimbursed.)

Receipts for each OTC drug identifying the drug, dosage (if appropriate), and the amount paid. Please check

when you receive the receipt for the OTC drug to be sure the drug name on the original prescription matches

the one on the receipt.

5. For services received outside the United States, please submit an International Claim Form to the BlueCard®

Worldwide Service Center. To download the form, visit the Members portal of , click

Download a Form, then select International Claim.

6. Mail completed forms and itemized bills to:

Highmark Blue Cross Blue Shield Delaware

P.O. Box 8831

Wilmington, DE 19899-8831

* Please note the Customer Claim Form should be used to request reimbursement OTC drugs in the following situations:

If a member has pharmacy beneﬁts through Highmark Delaware and the beneﬁts are not indicated on the ID card (and he/she does not have

a separate prescription drug card).

If a member has a separate ID card for prescription drugs, and receives drug coverage through a separate pharmacy beneﬁts manager (PBM),

but the PBM will not process OTC drug coverage.

Did you remember to:

Attach your receipts

Submit your valid prescription for OTC drugs

Indicate the diagnosis

Date this claim form

Sign this claim form

Thank you for choosing Highmark Blue Cross Blue Shield Delaware. We look forward to serving you.

Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association

Customer Claim Form - Highmark Blue Cross Blue Shield Delaware Page 2

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