[PDF] [PDF] Member Claim Form - MPIPHP

[PDF] Anthem Blue Cross Provider Contacts

Anthem Blue Cross PO Box 60007 Los Angeles, CA 90060-0007 E-Solutions: Electronic claims submission for Institutional, Medical Dental only ERA (835

[PDF] Anthem Medical Claim Form

Health care services: Use this section to report any COVERED health service that has not already been reported to this Anthem Blue Cross and Blue Shield

[PDF] Anthem Blue Cross-HMO - OPM

Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing  

[PDF] Member Claim Form - MPIPHP

MEDICAL INFORMATION PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross Card) Member Claim Form Please use a separate 

[PDF] Typical Costs for Common Medical Services - Blue Cross Blue Shield

Understanding the cost of the medical care you receive is an important part of Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the 

[PDF] Anthem Blue Cross and Blue Shield Anthem Silver - NHgov

This plan may encourage you to use In-Network provider by charging you lower deductibles, copayments and coinsurance amounts Common Medical Event

[PDF] Anthem Blue Cross Blue Shield Platinum

There are no other medical expenses for any member covered under this plan • Out-of-pocket expenses are based only on treating the condition in the example •  

[PDF] Anthem Blue Cross Blue Shield Medical Plan - ResourceONE

Anthem Blue Cross Blue Shield Medical Plan – ACP Only 1 12/12 The following highlights the differences between the medical, prescription drug and vision

[PDF] Anthem Blue Cross Blue Shield: Anthem Silver Guided - AOTA

If you use a network provider (doctor or other network healthcare provider), this plan will pay some or all of the costs of covered services Be aware, your network  

[PDF] anthem blue cross payer id

[PDF] anthem blue view vision warby parker

[PDF] anthem dental payer id

[PDF] anthem electronic payer id

[PDF] anthem healthkeepers payer id

[PDF] anthem insurance companies

[PDF] anthem medicare payer id

[PDF] anthem payer id for indiana

[PDF] anthem payer id or edi

[PDF] anthony "harv" ellison

[PDF] anthracene and maleic anhydride balanced equation

[PDF] anthracene and maleic anhydride product nmr

[PDF] anthracene maleic anhydride diels alder adduct melting point

[PDF] anthracene undergoes diels alder reaction

[PDF] anti 4th of july 2020

DATE OF SERVICE

(Mo/Day/Yr)PROVIDER OF SERVICE (Name of Doctor, Lab, Amb. Co., etc.)SERVICE RENDERED (Office Visit, X-ray, etc.)ILLNESS OR DIAGNOSIS TOTAL GRAND T OTAL NAME Last First Middle Initial MEMBER ID GROUP NUMBER

BIRTHDATE SEX RELATION TO SUBSCRIBER NAME Last First Middle InitialDOES THE PATIENT HAVE OTHER HEALTH INSURANCE COVERAGE? ADDRESS

NAME OF OTHER HEALTH INSURANCE COMPANY CITY STATE ZIP CODE

POLICY NUMBERHOME PHONE NO. WORK PHONE NO.

MEDICAL INFORMATION

PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross Card)Member Claim Form

Please use a separate claim form for each patient. Your cooperation in completing all items on the claim form and attaching all required

documentation will help expedite quick and accurate processing. PLEASE TYPE or PRINT • SEE REVERSE SIDE FOR COMPLETE INSTRUCTIONSMF

Self Spouse Son Daughter

Yes No

HEALTH CARE SERVICES:Use this section to report any COVERED health service that has not already been reported to this Anthem Blue Cross

Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill or photocopy. Please besure that duplicate bills are not submitted.

Wasthis medical expense the result of an accident? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Was this condition or injury job related? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Haveyou filed for Workers" Compensation?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

Onwhatdaydid this injury or accident occur?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Month:____ Day:____ Year:____

Have you been treated for the same condition within the last 24 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

If yes, indicate date you were last treated: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Month:____ Day:____ Year:____If thebill is from a Licensed Clinical Social Worker; Marriage, Family and Child Counselor; Audiologist; or Occupational,

Physical, or Speech Therapist; what is the name of the physician who ordered the service?

Dr. ______________________________________________________________________________________Icertify that the information on this Member Claim Form is true and correct to the best of my knowledge. I authorize the release of any medical

information necessary to process this claim. X

SIGNATURE OF SUBSCRIBER DATEAnthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association.

®ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.

anthem.com/caIU2013 Effective 6/08

HOW TO USE THIS FORM

Dear Member:

U

sually, all providers of health care will bill us for services to you and your enrolled dependents. This is the preferred procedure. You are not

bothered with claim forms and we often need more details than are ordinarily provided on bills to patients.

S

ometimes, a physician may not bill us, or an ambulance company, for example, may send the bill directly to you. In either instance, we have

no way of knowing about your claim. This Member Claim Form was developed to notify us of any covered health service for which we have not

already been billed. Please read the following instructions about how to report Health Care Services.

W eare happy to serve you. PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross Card)

Use this section to identify the patient and subscriber. Some of this information may be found on your Anthem Blue Cross card.

MEDICAL INFORMATION

HEALTH CARE SERVICES: Use this section to report any COVERED health service which has not already been reported to this Anthem Blue Cross

Plan by the provider of service (the physician, clinical, ambulance company, private duty nurse, etc.) Attach itemized bill or photocopy. Please be

sure that duplicate bills are not submitted. D ATE OF SERVICE PROVIDER OF SERVICE SERVICE RENDEREDILLNESS OR DIAGNOSIS TOTAL (Mo/Day/Yr) (Name of Doctor, Lab, Amb. Co., etc.) (Office Visit, X-ray, etc.)

5/9/08 John Wang, M.D. Office Visit Bronchitis $35.00

5/9/08Pat Fogarty, M.D. X-ray Strain $57.00

GRAND TOTAL $92.00 THE FOLLOWING INFORMATION MUST ALSO BE INCLUDED ON BILLS FOR THESE ITEMS:

REGISTERED AND LICENSED VOCATIONAL NURSES:

Hours and dates of service

Location of service (residence or name of hospital)

Written documentation of physician"s referral (must include the state license number, plan of treatment and estimated duration

of treatments) PROSTHETIC DEVICES, APPLIANCES OR DURABLE MEDICAL EQUIPMENT:

Doctor"s orders or prescription

Purchase price

AMBULANCE:

Pick-up and delivery points

Number of miles

BILLS MUST BE ITEMIZED:

Cancelled checks, cash register receipts and non-itemized "balance due" statements cannot be processed. Each itemized bill must include:

Name and address of provider (doctor, hospital, laboratory, ambulance service, etc.)

Nameofpatient

Service provided

Date of service

Amount charged for each service

Diagnosis

MEMBER CLAIM FORM INSTRUCTIONS:

For services rendered in California,please send claims to P.O. Box 60007, Los Angeles, CA 90060 For

out-of-stateclaims, pleasecontact Customer Service for the claims office address. Out-of-state claims must be sent to the Blue Plan

of the state in which services were rendered. For your convenience, the Customer Service number is listed on your Member ID card.

NOTE:If your coverage includes Prescription Drug benefits, call (800or customer assistance.quotesdbs_dbs10.pdfusesText_16