International Claim Form - Blue Cross Blue Shield Global Page 2
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2General Information
• The Blue Cross Blue Shield Global Core International Claim Form is to be used to submit institutional and professional claims for benefits
for covered services received outside the United States, Puerto Rico and the U.S. Virgin Islands.
• For other claim types (e.g., dental, prescription drugs), contact your Blue Cross and Blue Shield Company for filing instructions.
• Please complete all fields. If the information requested does not apply to the patient, indicate N/A (Not Applicable).
• Please attach receipts and medical records (test results, x-rays, etc.), if available.
• Please keep photocopies of all 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 in local currency
SPECIAL CARE SHOULD BE TAKEN WHEN COMPLETING THE FOLLOWING FIELDS:
1. Patient Information
1E. Name of subscriber – For check payments, provide your full name (initials are not acceptable).
1H. Subscriber’s current mailing address – If check payment is requested, this address will be used. Please provide your physical address
(payments cannot be sent to a P .O. Box).
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 the attached bills. Although itemized bills from the provider showing a separate charge for each service must be submitted,
your listing will enable us to process the claim more quickly. If additional space is needed, 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 —as indicated on the bill. If the bill has already been paid, please indicate the date it was paid.
5. Payee
Option A. Make payment to subscriber, designation of currency and payment method — 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 may charge a fee to receive a wire. You may want to research fees charged by your bank prior to requesting a wire since
you will be responsible for any such fees.
For an electronic funds transfer, provide the bank’s physical address where the account was opened (not a P .O. Box). Please provide a copy of a
voided check or deposit slip so that the bank information can be validated.
Option B. Authorization for payment to provider — complete option B if you prefer that benefits be paid directly to the provider of service.
Direct payment to the provider is at the discretion of your Blue Cross and Blue Shield Company, except where required by law.
6. Signature
The International Claim Form must be signed and dated by the subscriber, spouse, or the patient.
Disclosure Statement
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
16-581-N35
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