Form Cut0159-1s - Overseas Medical Claim Form (English) Page 2

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FEDERAL EMPLOYEE PROGRAM OVERSEAS MEDICAL CLAIM FORM
PLEASE USE THE RETAIL PRESCRIPTION DRUG OVERSEAS CLAIM FORM FOR ALL PRESCRIPTION DRUGS
PURCHASED AT PHARMACIES OUTSIDE OF THE UNITED STATES, PUERTO RICO, AND THE U.S. VIRGIN ISLANDS
GENERAL INFORMATION
This Overseas Medical Claim Form is to be used to submit a claim for benefits for covered services received outside the United States, Puerto
Rico, and the U.S. Virgin Islands. Please complete a separate claim form for each patient and remember to file all claims by December 31 of
the calendar year after the one in which the covered care or service was provided.
The Overseas Medical Claim Form must be completed in full, and accompanied by fully itemized bills. Please be sure to keep photocopies of
all bills and supporting documentation for your personal records.
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
OVERSEAS MEDICAL 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:
OTHER HEALTH INSURANCE – If the patient holds other insurance coverage, please complete items 2A through 2K 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 Policy Holder 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
.
A clear photocopy of the other carrier's Explanation of Benefits Form is acceptable in place of the original document.
DIAGNOSIS – Describe reason for visit, illness, injury, or symptoms requiring treatment, e.g. cough, sore throat.
CHARGES – Please list here the number of bills that are being included on this claim. Please attach itemized bills for all services. Please list
the beginning date and the end date of service.
A. Begin Date- The first date of service for which benefits are being claimed
B. End Date- The last date of service for which benefits are being claimed
C. Total Charges- The total amount being claimed for all bills attached.
D. Number of Itemized Bills Attached- Total number of itemized bills for all services being claimed.
MEMBER REIMBURSEMENT INFORMATION – Make reimbursement to contract holder designation of currency and payment
method – Indicate whether you want to be paid in the currency reflected on the bill(s) or in U.S. dollars and if you want to receive payment
via check or bank wire. If you choose reimbursement via a bank wire, payment can only be issued to the contract holder's bank
account. 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. Omission or errors in
payment information will result in receipt of a check in US Dollars.
BANK WIRE INFORMATION – You must include the following information on this form: your full name (initials are not acceptable) and
your physical address. For wire payments, contract holder'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 and IBAN numbers. 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 (ABA/SWIFT).
Complete this item if you prefer that benefits be paid directly to the provider of service
AUTHORIZATION FOR ASSIGNMENT OF BENEFITS –
.
SIGNATURE – The Overseas Medical Claim Form must be signed and dated by the Contract Holder, spouse, or the patient.
Submission acts as signature for e-Claims
THIS COMPLETED CLAIM FORM, TOGETHER WITH ITEMIZED BILLS AND SUPPORTING DOCUMENTATION, SHOULD BE
SUBMITTED TO:
Federal Employee Program (FEP) Overseas Claims, PO Box 261570, Miami, FL 33126
YOU CAN ALSO FAX YOUR CLAIMS TO EITHER 1-888-650-6525 OR 410-781-7637
DEPENDING ON THE LOCATION THAT YOU FAX FROM, YOU MAY NOT NEED TO ADD THE 1 IN FRONT OF THE 888 FAX NUMBER.
ADDITIONAL CLAIM FORMS and FAX DIALING INSTRUCTIONS AVAILABLE ON OR BY CALLING 1-888-999-9862
CUT0159-1S 5/14

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