INSURED COMPLETES

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					MEDICAL INSURANCE CLAIM FORM
EMPIRE BLUECROSS BLUESHIELD

PLEASE DO NOT USE THIS AREA

PO BOX 170, NEW YORK, NY 10156-0170
An independent member of the Blue Cross and Blue Shield Association

INFORMATION ABOUT THE PATIENT
1.PATIENT’S NAME (FIRST)
2.PATIENT’S SEX

INFORMATION ABOUT THE INSURED
12.IDENTIFICATION NUMBER
(INCLUDE PREFIX AND SUFFIX, IF ANY) IF YES, SEE BACK OF FORM FOR MEDICARE ELIGIBILITY

(LAST)
4. DOES PATIENT HAVE MEDICARE PART B?

3. PATIENT’S BIRTHDATE

YES NO

13. INSURED’S NAME (FIRST) 14.INSURED’S SEX

(LAST)

M
INSURED COMPLETES

F
MONTH DAY YEAR

15.GROUP NUMBER (IF ANY)

M

F
APT.NO

5.PATIENT’S RELATIONSHIP TO THE INSURED

16. INSURED’S EMPLOYER

SELF
8.IS PATIENT A FULL TIME STUDENT?
9.WAS CONDITION RELATED TO:

SPOUSE YES NO

CHILD

OTHER (SPECIFY)
7.PATIENT’S TELEPHONE NUMBER

6.PATIENT’S OCCUPATION OR EMPLOYER

17.INSURED’S HOME ADDRESS (NO. AND STREET) 18.CITY STATE

(
IF YES, NAME OF SCHOOL

)
ZIP CODE

AUTO INJURY?

YES

NO

19.IN CARE OF
MOTORCYLE INJURY? YES NO

YES NO ON THE JOB INJURY? 10. DOES PATIENT HAVE ANY OTHER HEALTH INSURANCE?

YES

NO

IF YES, PLEASE GIVE THE INSURANCE COMPANY NAME, ADDRESS AND THE POLICY NUMBER, OR ATTACH YOUR OTHER COVERAGE EXPLANATION OF BENEFITS

11. I AUTHORIZE THE RELEASE OF INFORMATION AS DESCRIBED ON THE REVERSE SIDE OF THIS CLAIM FORM DATE SIGNED

PATIENT’S OR AUTHORIZED SIGNATURE

MONTH

DAY

YEAR

20.PLACE THE SERVICE WAS RENDERED: HOSPITAL
(INPATIENT)

21.DATE ADMITTED MONTH DAY YEAR 26. EMERGENCY RELATED?

22.DATE DISCHARGED MONTH DAY YEAR

23.DATE OF ONSET MONTH DAY YEAR

24..DATE FIRST CONSULTED FOR CONDITION MONTH DAY YEAR

HOSPITAL
(OUTPATIENT)

OFFICE

25. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?

YES NO

PROVIDER COMPLETES

OTHER (SPECIFY) _____________________

YES NO

27.WAS SURGERY PERFORMED?

YES NO

27A. IF YES, TYPE OF SURGERY

27B.DATE OF SURGERY MONTH DAY YEAR

28.NAME AND ADDRESS OF THE FACILITY WHERE THE SERVICE WAS RENDERED

29.NAME AND ADDRESS OF REFERRING PHYSICIAN OR OTHER PROVIDER

30.DIAGNOSIS OR NATURE OF ILLNESS.RELATE WRITTEN DIAGNOSIS TO PROCEDURE BY ENTERING LINE 1,2,3 OR ICD-9 CODE IN DIAGNOSIS, COLUMN 37 BELOW

1. 2. 3.
31.PLACE 32.TYPE 33.PROCEDURE 34.MOD 35.MOD (HCFA/CPT4) 36.FULLY DESCRIBE PROCEDURES, MEDICAL SERVICES OR SUPPLIES FURNISHED FOR EACH DATE GIVEN (EXPLAIN UNUSUAL CIRCUMSTANCES) 37.DIAGNOSIS CODE (ICD-9) 38.DATES OF SERVICE FROM
MONTH DAY YEAR

TO
MONTH DAY YEAR

39. DAYS OR UNITS

40. CHARGE

42.

”I CERTIFY THAT THE CARE, SERVICES AND SUPPLIES ENTERED ON THIS FORM HAVE BEEN RENDERED TO THE PATIENT, AND THAT I AM ENTITLED TO REIMBURSEMENT OF THE CHARGES INDICATED.”

43. MY FEE HAS BEEN PAID HAS NOT BEEN PAID
DATE SIGNED:

41.TOTAL CHARGES
44.PROVIDER’S TAX IDENTIFICATION NU MBER 45.TELEPHONE NUMBER

(
46.PROVIDER’S NAME, ADDRESS AND ZIP CODE

)

PROVIDER’S SIGNATURE

MONTH

DAY

YEAR 47. PROVIDER’S EMPIRE BLUE CROSS AND BLUE SHIELD NO.

PATIENT AND INSURED INSTRUCTIONS
We need all of the information requested on the front of this form to process your claim. Please help us to serve you by filling in all the boxes asking for information about the patient and the insured on the upper part of the claim form labeled “Insured Completes”. Please print or type. THIS NEW CLAIM FORM SUPPORTS IMAGING TECHNOLOGY WHICH WILL IMPROVE SERVICE TO OUR VALUED CUSTOMER IMPORTANT – COPY YOUR IDENTIFICATION NUMBER EXACTLY AS IT APPEARS ON YOUR IDENTIFICATION CARD After filling in the “Insured Completes” section (the top of the form), please give this form to your physician or provider who can fill in the “Provider Completes” section or just attach original bills. To submit bills, please refer to the “Original Bill Submission Instructions” section below.

MEDICARE ELIGIBILITY INSTRUCTIONS
Patients over the age of 65 may be eligible for Medicare benefits or they may be covered by their own or their spouse’s insurance. Please follow the steps below to determine your primary coverage and help us process this form correctly. 1. Is the patient over 65? Yes No 2. Is the patient actively employed? Yes No 3. If the patient is married, is the patient’s spouse actively employed? Yes No If the answer to question 1 is yes and the answer to questions 2 and 3 is no, then Medicare is the patient’s primary health coverage. Submit your Medicare claim first. Once it has been processed by Medicare, please forward the Explanation of Medicare Benefits (EOMB) to us to determine if further benefits may be available under your Supplementary contract. If the answer to question 1 is yes and the answer to either question 2 or 3 is yes, then Medicare may not be the patient’s primary health coverage. The patient may hold primary coverage through a group where the patient or the patient’s spouse is actively employed. In this case, the patient is TEFRA/DEFRA eligible. Please enter the insured group number, if any, and employer name (see items 15 and 16 on front of form). Then, place an “X” after the identification number on the top of the claim form (see item 12 on front of form).

ORIGINAL BILL SUBMISSION INSTRUCTIONS
Bills must be originals (not photocopies) and must contain all of the information we need to process the claim. When submitting original bills, first make sure that the bill includes the following:  The physician’s or provider’s name and address.  The patient’s name and address.  The insured’s identification number.  The date of service (usually the date you saw the doctor or provider).  The charges (the provider’s fee) for each service.  A detailed description of services. If this is a doctor’s visit, the diagnosis or the name of the condition (for example, appendicitis, upper respiratory problem) must be included. If you have pharmaceutical coverage and you have a prescription drug bill, please make sure that the original bill includes the following:  Pharmacy name and address.  Quantity of each drug.  Purchase date.  Charge for each drug.  Prescription number.  Prescribing doctor’s name.  Name of each drug.  Patient’s name. If you have a private duty nursing coverage bill, please make sure the bills are submitted include the following:  The doctor’s written orders or authorization.  The nurse’s signature, professional title (LPN, RN), and the license number.  The place of service.  The hours of duty worked (for example, 8PM to 8AM). Since we cannot return your bills to you, please keep a copy of them for your own records. When submitting small size bills such as pharmacy bills, tape them to an 8 ½ by 11 sheet of paper and attach the paper to this claim form. This will prevent the loss of small bills and speed the accurate processing of your claim.

PATIENT’S SIGNATURE
The patient must sign the claim form , authorizing the release of information as described below. If the patient is a minor, the signature must be that of the patient’s parent or legal guardian. “I hereby authorize any physician, health care practitioner, hospital, clinic or other medical or medically-related facility to furnish any and all records pertaining to medical history, services rendered, or treatment given to me or my dependent for purposes of review, investigation or evaluation of this claim. I also authorize Empire Blue Cross and Blue Shield, or its agents, to disclose to a hospital or health care service plan, self-insurer or an insurer, any such medical information obtained if such disclosure is necessary to allow the processing of any claim. If my coverage is under a group contract held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit. This authorization shall become effective immediately upon execution and shall remain in effect for the duration of this claim or term of coverage of my insurance policy, including a reasonable time thereafter, until its final consummation. This authorization shall be binding upon me, my heirs, executors or administrators.”

PHYSICIAN OR SUPPLIER INFORMATION
See Item 31, Place of Service Codes
11--Office 12--Home 21--Inpatient Hospital 22--Outpatient Hospital 23--Emergency Room –-Hospital 24--Ambulatory Surgical Center 25--Birthing Center 26--Military Treatment Center 31--Skilled Nursing Facility 32--Nursing Facility 33--Custodial Care Facility 34--Hospice 41--Ambulance –-Land 42--Ambulance –- Air or Water 51--Inpatient Psychiatric Facility 52--Psychiatric Facility Partial Hospitalization 53--Community Mental Health Center 54--Intermediate Care Facility/Mentally Retarded 55--Residential Substance Abuse Treatment Facility 56--Psychiatric Residential Treatment Center 61--Comprehensive Inpatient Rehabilitation Facility 62--Comprehensive Outpatient Rehabilitation Facility 65--End Stage Renal Disease Treatment Facility 71--State or Local Public Health Clinic 72--Rural Health Clinic 81--Independent Laboratory 99--Other Unlisted Facility

See Item 32, Type Of Service Codes
1--Surgery 2--Assistant Surgeon 4--Anesthesia (General) 5--Radiology (Global) 6--In Hospital Medical 7--Other than Hospital 8--Laboratory 9--Consultation 0--Medical Diagnostic Test A--Ambulance B--Biologicals C--Blood D--Professional Component P--Purchase R--Rental S--Supplies T--Technical Component U--Used Durable Medical Equipment

INSURANCE FRAUDS PREVENTION ACT The following statement is printed pursuant to Regulation 95 of the New York State Insurance Department. “Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information, or conceals for the purposes of misleading information concerning any factual material thereto, commits a fraudulent insurance act, which is a crime.”