Transportation Claim Form - Blue Cross Blue Shield Of Alaska Page 2
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1
2INSTRUCTIONS
Complete a Transportation Claim Form.
A.
Attach travel documentation.
B.
Please do not highlight or modify the travel documentation as this may cause delayed
processing of your claim. Examples of travel documentation would include a boarding pass and copy of the ticket from the
transportation provider or a copy of the detailed itinerary.
The documentation must contain all of the following information:
Name of the passenger
Dates and total cost of travel
Origination and final destination points
Please note: Your claim will be returned if all of the information required above is not included.
Attach a statement or letter from your physician.
C.
This must indicate the medical necessity of the services you
received that required the air or surface travel.
The front of your member ID card
D.
may not match the card pictured below. This sample card is meant to be a guide
to help you identify your prefix, identification and group numbers. These numbers are required to complete your claim form.
A copy of your identification card is not required to process your claim.
Required Information Checklist
E.
Signed & completed Transportation Claim Form
Travel documentation such as boarding pass/ticket or detailed itinerary
Letter of medical necessity or a statement from provider stating that the service(s) are not available locally
030104 (12-2013)
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