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BCPSEA EHC claim form

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BCPSEA EHC claim form Powered By Docstoc
					                                                                                                                                                                                                                   BRITISH COLUMBIA
BCPSEA                                                                                                                                                                                             PUBLIC SCHOOL EMPLOYERS’
EHC claim form                                                                                                                                                                                                               ASSOCIATION
                                                                                                                                                                                                       Extended Health Care Claim Form
           PACIFIC

           BLUE CROSS                                   TM                         • Please read instructions on reverse before submitting this form. Ensure you have completed all sections.
                                                                                   • Enclose all original receipts. Keep a copy of the receipts for your records.
           Mailing Address                         Street Address                  • Please refer to your Pacific Blue Cross EHC card for your group, ID and dependent numbers.
           PO Box 7000                             4250 Canada Way
           Vancouver BC V6B 4E1                    Burnaby BC                      • For help completing this form, or for more information on your EHC plan, call us at 604-419-2600 or 1-888-275-4672.

MEMBER INFORMATION
  Company name                                                                         Member’s last name                                                    Member’s address

  Group number                         Member’s identity number                        Member’s first name                                                   Postal code                            Daytime phone number
 E                                                                                                                                                                                                 (           )
                                                                                       Member’s provincial health plan number (Care Card)              Member’s E-mail address
EXPENSE INFORMATION
    Name of dependent claiming        Birth date       Dependent     Type of expense or name of medication     Date of each purchase or service or       Amount            Provider/prescriber                     Nature of illness
 (list in dependent and date order)   mm/dd/yy          number          (Example: hospital, ambulance,        hospital admission and discharge dates      paid                  of service                            or injury
                                                                                or name of clinic)                          mm/dd/yy




My family is (or, I am) registered with                                                                                                                        Total Claim: $0.00
Fair PharmaCare                                        Yes          No      Do you or your dependents have other insurance                                          Pacific Blue Cross does not return receipts. Please save our Explanation
Is your claim the result of an accident?                                    to cover these benefits?         Yes           No                                       of Benefits for income tax purposes. If you also have coverage with
If yes, attach accident details.                       Yes          No                                                                                              another insurance company, make a photocopy of all receipts before
                                                                                                                                                                    sending the originals to Pacific Blue Cross.
                                                                              Name of the other insurance company
Is this a Workers’ Compensation                                                                                                                                     I certify that I and/or my dependents incurred these expenses. All information
(WCB) case?                                            Yes          No                                                                                              is correct.
                                                                              Group number                                   ID number                              I consent to Pacific Blue Cross using this personal information to
Is this an ICBC, or other
                                                                                                                                                                    adjudicate my claim and disclosing this information when required or
auto insurance, case?                                  Yes          No
                                                                              Name of member with other insurance company                                           permitted by law or pursuant to its contractual obligations under my
Are you seeking damages                                                                                                                                             benefit plan.
from a third party?                                    Yes          No                                                                                              I also authorize Pacific Blue Cross or its agents access to any relevant
                                                                              Effective date mm/dd/yy                        Cancellation date mm/dd/yy
                                                                                                                                                                    information required to adjudicate this claim.
Are any of these expenses due to a medical emergency while
you were outside of the province where you live? If yes, please
contact Pacific Blue Cross for an Out of Province claim form.
                                                                            If you are claiming for the balance not paid by the other insurance company,            X
                                                                            include photocopies of your receipts and their payment statement.
                                                                                                                                                                        Member’s signature                                             Date
10-60-023 03/07 CUPE 1816                                                                                      Morneau Sobeco
IMPORTANT CLAIMING INFORMATION                                                                         prosthetic appliances, ostomy supplies.) Submit to     HEARING AIDS
Please provide all information requested on both                                                       Fair PharmaCare for payment by March 31st of the
                                                                                                       year following the service or purchase. When you       Please check your plan brochure for any age
pages of this claim form. Pacific Blue Cross is                                                                                                               restrictions.
unable to process incomplete claims.                                                                   purchase prescription drugs, your pharmacist
                                                                                                       submits claims to Fair PharmaCare on your behalf.      REGISTERED NURSES
1) Submit all claims with itemized statements
    and original paid receipts, which indicate:                                                        To claim for the benefits listed below, see the        Along with your receipts, Pacific Blue Cross
                                                                                                       specific instructions.                                 requires a letter from the attending doctor,
    • patient’s name
                                                                                                       Check your plan brochure for a list of eligible        indicating the diagnosis, that he or she ordered
    • type of purchase or service
                                                                                                       benefits and the conditions when these benefits        the nurse’s services, and the necessity for the
    • date of each purchase or service                                                                                                                        services.
                                                                                                       are eligible.
    • amount charged for each purchase or service
                                                                                                       PRESCRIBED DRUGS                                       ORTHOPEDIC SHOES
Pacific Blue Cross is unable to accept                                                                        • official PharmaCare receipt                   Along with your receipts, Pacific Blue Cross
photocopies unless you have submitted the
                                                                                                       SERVICES (physiotherapist, chiropractor,               requires a letter from the orthopedic surgeon,
original receipts to your other insurance company.
                                                                                                                                                              doctor or podiatrist, indicating the diagnosis, the
If so, attach copies of your receipts and a copy of                                                    podiatrist, naturopath, massage
                                                                                                                                                              necessity for prescribing the shoes, and the type
their payment statement.                                                                               practitioner)                                          of shoes prescribed.
2) List all expenses in dependent and date                                                                    •    type of service
     order.                                                                                                   •    date of each treatment                     DENTAL ACCIDENTS
3) Pacific Blue Cross will only consider paying                                                               •    amount charged for each treatment          Along with your receipts, Pacific Blue Cross
     claims that exceed your deductible. See your                                                             •    therapist’s name and phone number          requires from the dentist a detailed list of
     Pacific Blue Cross EHC card or brochure for                                                                                                              services performed. We also require the exact
                                                                                                       HOSPITAL ACCOMMODATION                                 date of the accident, the circumstances of the
     information about your plan deductible.                                                                  •    type of room (semi-private, private)       accident, and information on any other dental
4) All claims must be received in the office of                                                               •    admission and discharge dates              coverage. Include all relevant X-rays.
     Pacific Blue Cross no later than December                                                                •    daily charge
     31st of the year following the date of purchase                                                                                                          THIRD PARTY LIABILITY
                                                                                                              •    a description of any additional charges
     or service (unless otherwise agreed upon by                                                                                                              Your EHC plan does not pay for any benefits if a
     your Employer). Late submissions will not be                                                      AMBULANCE                                              third party is liable by law. For claims due to an
     accepted.                                                                                                •    reason for taking the ambulance            accident, indicate if there is possible third party
5) Submit your EHC claims regularly (Pacific                                                                  •    date of service                            liability. If yes, please contact Pacific Blue Cross
     Blue Cross suggests about every three                                                                    •    places ambulance taken from and to         for further information, as you must complete
     months). Do not hold your claims until the                                                               •    amount charged                             third party forms.
     claiming deadline.
                                                                                                       OUT OF PROVINCE                                        VISION CARE
Your EHC plan may include a deductible and a                                                                                                                  Not all EHC plans cover vision care benefits.
reimbursement percentage (example: $25.00
                                                                                                       MEDICAL EXPENSES
                                                                                                       Please contact your plan administrator to obtain       Check your plan brochure. Submit itemized
deductible, balance paid at 80%). Check your                                                                                                                  receipts, that show the purchase date and the
plan brochure for details.                                                                             the following forms:
                                                                                                                                                              patient’s name.
All BC residents covered by the Medical Services                                                           • MSP Out-of-Country claim form
Plan of BC are eligible for Fair PharmaCare                                                                • Emergency Out-of-Province Expense claim
benefits. If you have not already done so, please                                                              form
register with Fair PharmaCare in order to maximize                                                         • Schedule A
your financial eligibility. Expenses paid in part by                                                   Complete all necessary forms and submit to                           Secure online access
Pacific Blue Cross may be eligible with Fair                                                           Pacific Blue Cross promptly in order that we may                   to benefit information for
PharmaCare and should be submitted to Fair                                                             submit your claim to MSP within their 90 day                     Pacific Blue Cross members.
PharmaCare first for their consideration. (Examples:                                                   deadline.                                                          www.pac.bluecross.ca
™ Pacific Blue Cross, the registered trade name of PBC Health Benefits Society, is an independent licensee of the Canadian Association of Blue Cross Plans.

				
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