9.24 Group Administrator s Manual

Transcription

1 9.24 Group Administrator s Manual Claim Form (NF 43A) (Instructions) keb/a2/8400/24.docx (8/2017)

2 Group Administrator s Manual 9.25 Claim Form (NF 43A) (Instructions) keb/a2/8400/25.docx (8/2017)

3 9.26 Group Administrator s Manual 15 keb/a2/8400/26.docx (8/2017)

4 Group Administrator s Manual 9.27 Completing a Capital BlueCross Claim Form NF 43A The following information must be included with the claim: SECTION Patient/Member Name the first and last name of the patient who received the service. ID Number the subscriber s three-letter alpha prefix and nine-digit identification number. Group Number (Group ID) the identification number of the sponsoring group or employer. (Patient s) Date of Birth patient s date of birth by month, day, and year. Gender the gender of the patient. (Patient s) Relationship to Subscriber relationship of patient to the subscriber. SECTION Subscriber Name full name of the person enrolled for coverage through the group. (Subscriber s) Date of Birth Subscriber s date of birth by month, day, and year. Employee Status the subscriber s employment status. Present Address the full address of the subscriber including: number and street, city, state, country, and ZIP Code. SECTION 3 11 Describe Conditions for Which You Are Requesting Benefits at This Time describe the specific diagnosis, type of illness, or injury; provide the name and degree of the provider and the date you first received treatment from this provider for this condition. keb/a2/8400/27.docx (8/2017)

5 9.28 Group Administrator s Manual Completing a Capital BlueCross Claim Form NF 43A (continued) SECTION 4 12 Were Expenses Due to an Accidental Injury check the applicable box: Yes if the treatment was needed as the result of an injury, No if it was not related to an injury. If related to an injury, provide the following information: a. Date of Accident the month, date, and year on which the injury occurred. Place/Type of Incident check the box that best describes your situation or complete Other. b. Description briefly describe the situation that caused the injury. c. Workers Compensation indicate if a claim has been filed. d. Responsible Party indicate if the member will be filing a complaint against another person as a result of his or her injury. SECTION 5 13 Medicare Check No if the member is not enrolled in Medicare Part A. Check Yes if the member is enrolled in Medicare Part A and give the date when that coverage began. Check No if the member is not entitled to benefits under Medicare Part B. Check Yes if the member is entitled to benefits under Medicare Part B and give the date when that coverage began. Enter the number found on the member s Medicare ID card. Indicate Yes if the services were rendered as the result of a Medical Emergency in a foreign country and give a description of the situation, or No if they were not. keb/a2/8400/28.docx (8/2017)

6 Group Administrator s Manual 9.29 Completing a Capital BlueCross Claim Form NF 43A (continued) SECTION 6 14 Other Coverage Check: Yes if the patient has coverage through another insurance plan, and complete the rest of this section, or check No, if the patient has no other insurance coverage. Completion of this section avoids duplicate payment for losses covered under more than one insurance plan. a. Insured s Name the name of the person who is covered by the other plan. b. Employer s Name the name of the company where the person in 14a is employed. c. Insurance Company s Name the name of the company that provides the coverage for the person in 14a. d. Policy/Identification No. the policy identification number, date when the coverage began, the date other coverage was cancelled, and the employment status for the person in 14a. e. Check the applicable boxes indicating the Type of Coverage and Type of Health Insurance for the other coverage. SECTION & 18 Member Signature the member s signature. Date the date the form was signed. Phone Numbers the home and work telephone numbers of the person submitting the claim. keb/a2/8400/29.docx (8/2017)

7 9.30 Group Administrator s Manual Completing a Capital BlueCross Claim Form NF 43A (continued) Other Information If the following items apply to the member s circumstances, he/she must also provide the information requested: Itemized bills from the provider must include a date of service, diagnosis code, procedure code, and separate charge amount for each service. Other insurance payment or rejection notices including a Medicare Summary notice, if applicable, or Workers Compensation payment or rejection notice. Student information. Medical Records, which may include physician notes and/or treatment plans. Ambulance information - point of origin and destinations (example: from home to hospital). Home Health Care the type of service, the dates of service, and some benefits require Preauthorization. Anesthesia length of time the patient was under anesthesia and the specific type of surgery for which anesthesia was given. Blood the number of pints received, the charge for each pint, and the number of pints replaced by donor(s). Chemotherapy the name of the drug, dosage of drug, charge for each drug, and the method of administration (oral, intramuscular injections, intravenous, etc.). Home Medical Equipment certification from the prescribing physician concerning the medical necessity and expected length of time equipment is needed. If renting equipment, please have the supplier provide the equipment purchase price. keb/a2/8400/30.docx (8/2017)

8 Group Administrator s Manual 9.31 Claim Form (NF 43A) (Reverse) keb/a2/8400/31.docx (8/2017)