Form F7403r07 - Bcbs Subscriber Claim Form (Page 2 of 2) in pdf

Form F7403r07 - Bcbs Subscriber Claim Form Page 2

IMPORTANT, PLEASE READ THE FOLLOWING: Claims must be submitted with the timeframe specified by your contract.

HOW TO SUBMIT YOUR CLAIM:

1. Complete a separate Subscriber Claim Form for each patient and for each provider.

2. Answer all questions.

3. Attach a copy of the itemized bill. The bill should show:

 the provider’s name and address and Federal tax ID or National Provider Identifier (NPI)

 the diagnosis or the symptoms of illness

 the date, place and type of service

 the charge for each service

4. Attach a copy of your Explanation of Health Care Benefits, if you have other coverage as primary.

NOTE: We cannot return the claim or documentation that you send. Please make copies for your personal files.

Mail this form to:

Blue Cross and Blue Shield of Minnesota

PO Box 64338

St. Paul, MN 55164-0338

Fax this form to:

651-662-7933

Email this form to:

This information is also available in other ways to people with disabilities by calling customer service at (651) 662-8000

(voice), or 1-800-382-2000 (toll free).

For TTY:

Call (651) 662-8700, or 1-888-878-0137 (TTY), or 711, or through the Minnesota Relay direct access numbers at 1-800-

627-3529 (TTY, Voice, ASCII, Hearing Carry Over), or 1-877-627-3848 (Speech-to-Speech).

Hours: 7 a.m. to 8 p.m. Central Time, Monday through Friday

Attention: If you want free help translating this information, call the above number.

Atención: Si desea ayuda gratis para traducir esta información, llame al número que aparece arriba.

F7403R07 (11/13)

Form F7403r07 - Bcbs Subscriber Claim Form Page 2