Health Insurance Claim Form - The Empire Plan - United Healthcare

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New York State Government Employees
Health Insurance Program
UnitedHealthcare
P.O. Box 1600
HEALTH INSURANCE CLAIM FORM
Kingston, New York 12402-1600
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12
1-877-7NYSHIP (1-877-769-7447)
OR FAX TO (845) 336-7716
PICA
PICA
1a. INSURED’S I.D. NUMBER
(For Program In Item 1)
1. MEDICARE
MEDICAID
TRICARE
CHAMPVA
GROUP
FECA
OTHER
HEALTH PLAN
BLK LUNG
(Medicare #)
(Medicaid #)
(ID#/DoD#)
(Member ID #)
(ID #)
(ID #)
(ID #)
2. PATIENT’S NAME
3. PATIENT’S BIRTH DATE
SEX
4. INSURED’S NAME
(Last Name, First Name, Middle Initial)
(Last Name, First Name, Middle Initial)
MM
DD
YY
M
F
5. PATIENT’S ADDRESS
6. PATIENT RELATIONSHIP TO INSURED
7. INSURED’S ADDRESS
(No., Street)
(No., Street)
Self
Spouse
Child
Other
8. RESERVED FOR NUCC USE
CITY
STATE
CITY
STATE
ZIP CODE
TELEPHONE
(Include Area Code)
ZIP CODE
TELEPHONE
(Include Area Code)
(
)
(
)
9. OTHER INSURED’S NAME
(Last Name, First Name, Middle Initial)
10. IS PATIENT’S CONDITION RELATED TO:
11. INSURED’S POLICY GROUP OR FECA NUMBER
30500
a. EMPLOYMENT? (Current or Previous)
a. INSURED’S DATE OF BIRTH
SEX
a. OTHER INSURED’S POLICY OR GROUP NUMBER
YES
NO
MM
DD
YY
M
F
b. AUTO ACCIDENT?
PLACE (State)
b. RESERVED FOR NUCC USE
b. OTHER CLAIM ID (Designated by NUCC)
YES
NO
c. OTHER ACCIDENT?
c. INSURANCE PLAN NAME OR PROGRAM NAME
c. RESERVED FOR NUCC USE
YES
NO
EMPIRE PLAN
d. INSURANCE PLAN NAME OR PROGRAM NAME
10d. CLAIM CODES (Designated by NUCC)
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
YES
NO
If yes, complete items 9, 9a and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize
payment of medical benefits to the undersigned physician or supplier for
12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to
services described below.
process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.
SIGNED ________________________________________________________________
DATE ____________________________
SIGNED _________________________________________________________
15. OTHER DATE
16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION.
14. DATE OF CURRENT ILLNESS, INJURY or PREGNANCY (LMP):
QUAL
MM
DD
YY
MM
DD
YY
MM
DD
YY
MM
DD
YY
FROM
TO
QUAL
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE
17a.
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES.
MM
DD
YY
MM
DD
YY
17b.
NPI
FROM
TO
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)
20. OUTSIDE LAB?
$ CHARGES
YES
NO
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate A-L to service line below (24E)
ICD Ind.
22. RESUBMISSION
ORIGINAL REF. NO.
CODE
A.
| _____________________
B. | _____________________
C. | _____________________
D. | _____________________
E.
| _____________________
F. | _____________________
G. | _____________________
H. | _____________________
23. PRIOR AUTHORIZATION NUMBER
I.
| _____________________
J. | _____________________
K. | _____________________
L. | _____________________
24. A.
DATE(S) OF SERVICE
B.
C.
D. PROCEDURES, SERVICES, OR SUPPLIES
E
F
G
H
I
J
(Explain Unusual Circumstances)
DAYS
EPSDT
ID
RENDERING
From
To
DIAGNOSIS
Place of
OR
Family
QUAL
PROVIDER ID. #
POINTER
$ CHARGES
MM
DD
YY
MM
DD
YY
Service
EMG
CPT/HCPCS
MODIFIER
UNITS
Plan
1
NPI
2
NPI
3
NPI
4
NPI
5
NPI
6
NPI
25. FEDERAL TAX I.D. NUMBER
SSN
EIN
26. PATIENT’S ACCOUNT N0.
27. ACCEPT ASSIGNMENT?
28. TOTAL CHARGE
29. AMOUNT PAID
30. Rsvd for NUCC Use
(For govt. claims, see back)
YES
NO
$
$
31. SIGNATURE OF PHYSICIAN OR SUPPLIER
32. SERVICE FACILITY LOCATION INFORMATION
33. BILLING PROVIDER INFO & PH #
(
)
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.)
a.
b.
a.
b.
SIGNED
DATE
NPI
NPI
NUCC Instruction Manual available at:
PLEASE PRINT OR TYPE
APPROVED OMB-0938-1197 FORM 1500 (02-12)

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