Member Claim Form
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1
2Member Claim Form
o not file prescription drugs on this form. Type or use blue or black ink to complete.
•
Visit for prescription drug, dental and international claim forms, or call the toll-free number on your ID card.
Filing Requirements:
•
Complete a separate claim form for each covered family member.
•
Enclose itemized receipts and make copies for your records. See Section IV for required information.
•
Do not file a claim if the provider is filing for the same services.
•
Attach Explanation of Benefits if these services are covered by another insurance policy.
•
Claims must be filed within 18 months from the date services were received, or they will be denied.
•
Please see Section VI for mailing information.
ny claim filed without the required documentation listed above will be returned.
Please enter the subscriber number from your ID card.
SECTION I: Patient Information
Subscriber
Begin with
2 digits following member’s
Number:
name (see ID card)
letter prefix
Patient’s Last Name:
First Name:
Middle Initial:
Male
Self
Child
Date
Relationship
Sex:
of Birth:
to Subscriber:
Female
Spouse
Other:
Please check here if address has changed.
SECTION II: Mailing Information
Subscriber Name:
Address (Line 1):
Address (Line 2):
City:
State:
ZIP Code:
SECTION III: Other Insurance Information
Please complete the information below if the patient is covered by another health insurance policy.
Yes
Does the patient
Other health insurance
have other insurance?
No
company name:
Other policy
Other policy
number:
holder’s name:
Other policy holder’s
employer name:
Please complete the information below if the patient is covered by Medicare:
Part A
Is patient
Medicare health insurance
Part A and B
eligible for:
Part B
claim number:
If your other insurance or Medicare policy is primary, you must attach a copy of the Explanation
PLE SE NOTE:
of Benefits from that insurer. Your claim cannot be processed without this information.
n independent licensee of the Blue Cross and Blue Shield ssociation. ®,SM Marks of the Blue Cross and Blue Shield ssociation. SM1 Mark of Blue Cross and Blue Shield of North Carolina. BE236, 2/14
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Parent category: Business