Form No. 900508 - Claim Form (Page 2 of 2) in pdf

Form No. 900508 - Claim Form Page 2

IV. INSTRUCTIONS

STEP 3.

Review the bills for health care services that you will be sending, and please keep a copy as bills cannot be

returned. When filing for these services please include:

• For Physician Services — Professional Service Report (PSR) or Health Insurance Claim Form (HICF).

• For Hospital Services — local Blue Cross, Hospital, or UB92 Form.

OR, an itemized bill showing charges for each service the patient received. Each bill must show:

• The patient's name.

• The name, address, and professional status of the health care provider.

• The date of each service, the charge for each service, CPT code (a description of each service) and diagnosis

codes.

When filing for Private Duty Nurses or Home Care Equipment, include BOTH an itemized bill AND a letter of

Medical Necessity from your doctor.

If these same services were covered first by another health care plan (the patient's primary plan), make sure you

have copies of the other plan's statements showing how each service was paid. Use the bottom of this form for

prescription drugs.

STEP 4.

Sign the Authorization.

STEP 5.

MAIL YOUR COMPLETED CLAIM TO: Anthem Blue Cross and Blue Shield, P.O. Box 27401,

Richmond, VA 23279-7401

V. RECORD OF PRESCRIPTION DRUGS

A. If you use this form for prescription drugs, both sides must be completed.

Patient's Name: _______________________________________________________

Date ________________________________

Pharmacy's Name: _____________________________________________________________________________________________

Pharmacy Telephone Number: ___________________________________________________________________________________

1. A separate Record of Prescription Drugs must be kept for EACH PERSON enrolled.

2. This record should be used for:

• Drugs and medicines which can be dispensed by prescription only according to Federal and State law.

• Insulin and syringes prescribed for diabetic patients.

3. Other medications which do not require a prescription should not be recorded.

B. If you are attaching a signed pharmacy printout and/or the original receipt

that provides the requested information below, it is not necessary to fill out this part of the form.

Date of

Name and Strength

Quan-

Days

Prescription

Prescribing Doctor

Charge

Pharmacist Signature

Purchase

of Drug

tity

Supply

No.

TOTAL $ _____________________

Form No. 900508 - Claim Form Page 2

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