Instructions For Medical Claim Form For Non-California Claims printable pdf download

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NSTRUCTIONS FOR

EDICAL

LAIM

ORM FOR

ALIFORNIA

LAIMS

These instructions will advise you on how to prepare the attached Medical Claim Form to submit your

professional (non-hospital) claim to your local Blue Cross/Blue Shield office.

HO SHOULD USE THIS FORM

 If you are submitting a Non-California claim to your local Blue Cross/Blue Shield office and the medical bill

from your provider is not in the same format as the attached Medical Claim Form, you should attach a

Medical Claim Form to each itemized bill that you submit.

 Medical providers, if you are filing a claim on behalf of a participant but you do not use the same CMS-

1500 format as the attached Medical Claim Form. This form replaces the HCFA 1500.

ILLING OUT THE

ORM

Be sure to complete sections 1a, 2, 3, 4, 6, 7, and 11 as shown in the example below. The remaining sections may

be left blank.

DGA12345678J

DOE, JANE

01 21 60

DOE, JOHN

123 MAIN STREET

NEW YORK

10022

276945M001

 Box 1a/Insured’s I.D. Number. Be sure to enter your ID number as it appears on your Health Plan ID card,

including the “DGA” at the beginning and the “J” at the end. Do not use your social security number.

 Box 2/Patient’s Name. Enter the name exactly as it appears on the Health Plan ID card. If a dependent

child does not have a Health Plan ID card issued in their name, enter the child’s name exactly as it is on

file with the Health Plan.

 Box 4/Insured’s Name. (See Box 2 above.) If the insured person is also the patient, be sure to write the full

name in both Box 2 and Box 4. Do not write “self” or “same” instead of your name.

 Box 7/Insured’s Address. Be sure that your home address is entered exactly as the home address on file

with the Health Plan.

 Box 11/Insured’s Policy Group or FECA Number. Be sure to enter the Group Number that begins with

276945 from your Health Plan ID card.

HERE TO SUBMIT THE FORM

Claims should be sent to the Blue Cross/Blue Shield office in the area where the services were provided. For

example, if you live in New York but visit a doctor in New Jersey, your claim should be submitted to the Blue

Cross/Blue Shield office in New Jersey. To find the address of your local Blue Cross/Blue Shield office, please visit

INSTRUCTIONS FOR MEDICAL CLAIM FORM FOR NON-CALIFORNIA CLAIMS

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Instructions For Medical Claim Form For Non-California Claims