Health Insurance Claim Form - Blue Cross And Blue Shield Of Illinois Page 2
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1
2Filing Claims…
can be as easy as 1-2-3
1
Most Hospitals and Doctors will
Bill for the Following Services Should Show:
AMBULANCE SERVICE (Check your policy to make sure
file a claim directly with us.
you are covered for ambulance service):
Please show your Blue Cross and Blue Shield identification
• Date(s) when service was used.
card to the hospital or doctor. Most providers will file for you.
• Base rate and mileage.
• Place where patient was picked up and driven to.
If you are filing a claim, please fill out the reverse side of this form.
Help us avoid unnecessary delays by answering all questions
If transferred from one location to another, a letter from the
completely.
attending physician giving the reason for the transfer must be
attached to the bill.
2
Help us process your claims
Rental of Durable Medical Equipment:
quickly...Insist on itemized bills.
A statement from the attending physician stating why the equipment
We want to process your claims quickly, but we can’t do so without
was necessary must be attached to the bill. Also provide an estimate
properly itemized bills.
of how long the equipment will be used and the purchase price of
HERE’S WHAT WE URGE YOU TO DO:
the equipment.
1. Show the following instructions to the persons providing for your
health care and ask them for bills that follow these instructions.
If for long term use, please remember RENTAL IS PAID ONLY UP TO
2. Attach ORIGINAL BILLS to this claim form. We recommend that
THE PURCHASE PRICE OF THE EQUIPMENT.
you make copies of each bill for your personal records. The
original bills will not be returned.
Private Duty Nursing:
• Bills must show whether the nurse is a registered nurse or a
Is Medicare Your Primary Health Insurance Payer?
licensed practical nurse.
If YES, please be sure to send all bills to Medicare FIRST. (services not
• Nurse’s license or registry number.
covered by Medicare may be sent directly to BlueCross and BlueShield
• Date(s) of service.
FIRST). After you receive an “EXPLANATION OF BENEFITS” form from
• Type of care given.
Medicare showing what was paid, send a copy of this notification with
• Charge for each hour or shift.
your medical bills and completed Health Insurance claim form to us for
processing.
A letter from the physician stating why nursing care was
necessary, as well as the nurses progress notes, must be attached
Itemized Bills for Medical Treatment or Surgery
to the nurses bill.
Should Show:
• Physician’s name, address and phone number.
• Physician’s tax identification number.
• Full name of patient, not just name of person to whom bill is
addressed.
• Place where service was received (hospital, office or clinic).
• Diagnosis of illness or injury. If an injury give the date it
happened.
• Description of service received.
• Date of each treatment or surgical procedure.
• Charge for each treatment or surgical procedure.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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