Bluecard Worldwide International Claim Form (Page 2 of 2) in pdf

General Information

The BlueCard Worldwide International Claim Form is to be used to submit institutional and professional claims for benefits for covered

For filing instructions for other claim types

services received outside the United States, Puerto Rico and the U.S. Virgin Islands.

(e.g., dental, prescription drugs, etc.) contact your Blue Cross and Blue Shield Plan.

The International Claim Form must be completed for each patient in full, and accompanied by fully itemized bills. It is not necessary for you

to provide an English translation or convert currency.

Since the claim cannot be returned, please be sure to keep photocopies of all bills and supporting documentation for your personal records.

International Claim Form Instructions

Please complete all items on the claim form. If the information requested does not apply to the patient, indicate N/A (Not Applicable). Special

care should be taken when completing the following items:

2. Other Health Insurance

If the patient holds other insurance coverage, please complete items A through K as completely as possible. It is especially important to

indicate the name and address of the other insurance company and the policy or identification number of that coverage, as well as the name

and birth date of the person who holds that policy.

In addition, if the patient is someone other than the subscriber and has received benefits from any other health insurance plan held by reason

of law or employment, the Explanation of Benefits Form furnished by the other carrier pertaining to these charges must be included with the

claim. A clear photocopy of the other carrier’s Explanation of Benefits Form is acceptable in place of the original document.

4. Charges

Please list here the bills that are being included on this claim. Although itemized bills must also be submitted, your listing will enable us to

process the claim more quickly and accurately. If additional space is needed for listing charges, please use a separate sheet of paper to list the

following information.

4A. Name and Address of provider — as indicated on the bill. Multiple bills from the same provider may be included on the same line, as long

as they are for the same type of service.

4B. Type of provider — for example: hospital, nurse, physician, clinic, physical therapist, etc.

4C. Description of service — for example: hospital admission, office visit, x-ray, laboratory test, surgery, etc.

4D. Date of service or purchase — inclusive dates may be indicated for bills containing multiple dates of service.

4E. Charge — bills must be itemized to show a separate charge for each service. If the bill has already been paid, please indicate the date it

was paid.

5. Payee

— 1) Indicate whether you want to be paid in the

5A. Make payment to subscriber, designation of currency and payment method

currency reflected on the bill(s) or in U.S. dollars and if you want to receive payment via check or bank wire. Please note that not all forms

of currency may be available for payment. In the event that you select payment in a currency that is not available, you will be paid in U.S.

dollars. Banks will typically charge a flat fee or percentage-based fee to receive a wire. You may want to investigate fees charged by your

bank prior to requesting a wire since you will be responsible for any such fees.

2) You must include the following information on this form: your full name (initials are not acceptable), your physical address (payments

cannot be sent to a P .O. box). For wire payments, subscriber’s name as it appears on the bank account, the bank’s name and physical address

(payments cannot be wired to a P .O. box), account number, ABA number. Please provide a copy of a voided check or deposit slip so that the

bank information can be validated. Additionally, for wire payments to European Union countries, you must provide the International Bank

Account Number (IBAN) and Bank Identifier Code (BIC/SWIFT). For checks to be sent by express mail, you must provide a current telephone

number.

— complete item 5B if you prefer that benefits be paid directly to the provider of service. Direct

5B. Authorization for payment to provider

payment to the provider is at the discretion of Blue Cross and Blue Shield, except where required by law.

6. Signature

The International Claim Form must be signed and dated by the subscriber, spouse, or the patient.

Itemized Bill Information

Each provider’s original itemized bill must be attached and must contain:

– The letterhead indicating the name and address of the person or organization providing the service

– The full name of the patient receiving the service

– The date of each service

– A description of each service

– The charge for each service

This completed claim form, together with itemized bills and supporting documentation, should be submitted to:

BlueCard Worldwide Service Center

P .O. Box 72017

Richmond, VA 23255-2017 USA

N35-10-118

Bluecard Worldwide International Claim Form Page 2

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