Form C-53175 - Ppo/cmm Routine Vision Claim Form Page 2
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2MEMBER CLAIM FILING INFORMATION (HOW TO FILE)
Be sure to ask your provider of care if he/she bills Wellmark Blue Cross and Blue Shield of Iowa. Please submit itemized bills only
if the provider does not bill us directly. To receive benefits for drugs, or for services by a provider who does not bill us directly,
complete the claim form, attach itemized bills, and mail to: Wellmark Blue Cross and Blue Shield of Iowa, Station 39, PO Box 9291,
Des Moines, Iowa 50306-9291. Please do not use highlighter pens.
INSTRUCTIONS
A separate claim form must be submitted for each family member and each health care provider for all benefits.
1. Please complete all blanks.
2. Accurate answers to these questions will allow us to coordinate benefits with other sources of payment. This is also to insure
prompt and proper handling of your claim.
3. Your signature attests to the accuracy and completeness of all information on the claim and the attachments and authorizes
the release of your medical records by the provider to our office if necessary. Your telephone number will assist us if additional
information is required.
4. Write in the date services were provided.
5. Write in reason for medical care or diagnosis.
6. Place of service must be filled in with one of the following: Office, Home, Other.
REQUIRED INFORMATION FOR ITEMIZED BILLS
Itemized Bills: Summarizing the services may help us better understand the attachments if they are not clear. The attached
itemized bills must include the provider name and address, patient name, date of service, detailed description of service, place of
service, amount charged for that service, and diagnosis. These must be valid documents from the provider. Cancelled checks, cash
register receipts, or personally prepared bills will not be accepted. Please do not use highlighter pens.
Medicare: If the patient is eligible for Medicare benefits, you must attach a copy of the explanation of Medicare benefits
corresponding with each of the charges on the itemized bill submitted with this claim form. This claim cannot be processed without
this information.
Other Insurance: If the patient has received benefits under another insurance program, please attach a copy of the payment
document.
HELPFUL HINTS
•
If you have questions or need assistance, contact Wellmark Blue Cross and Blue Shield of Iowa at the number on your insurance
identification card.
•
To reduce the possibility of small billings getting lost or separated, it would be helpful if you attach these to an 8
⁄
x11 piece of
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paper. Please do not use highlighter pens.
•
File as soon as possible after the date of service. Your claim must be filed by the timely filing deadline. Please refer to your
coverage document for the specific timely filing guideline.
•
File only if the provider has not.
•
No part of your claim can be returned. If you need any of the itemized bill for your records, make a copy before mailing the claim.
Important: If the services for this claim were provided by a participating or contracting physician or hospital, the benefit payment
will be made to the provider.
Mail to:
Wellmark Blue Cross and Blue Shield of Iowa
Station 1E235
PO Box 9291
Des Moines, Iowa 50306-9291
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