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I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above.
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Authorization is hereby given to any hospital, physician, or other provider which participated in any way in my care and treatment to release to CareFirst BlueCross BlueShield any medical information which they in their judgement deem necessary to the adjudication of this claim.
STATE OF MARYLAND EMPLOYEES HEALTH CLAIM FORM
This form is to be used only by members of the State Employees Health Plan to file PPO, POS and EPO claims. While participating providers will bill CareFirst BlueCross BlueShield for services rendered, you may have claims to file yourself if you see non-participating providers.
• A copy of the bill on the provider’s letterhead stationary
IN ORDER FOR YOUR CLAIMS TO BE PROCESSED, THE FOLLOWING INFORMATION MUST BE SUBMITTED
The bill must include:
- Provider’s full name, degree, address, phone # and CareFirst BlueCross BlueShield provider number if available.
- Patient’s full name
- Descriptions of each service or supply
- Date of which each service was provided
- The provider’s diagnosis, or patient’s chief complaint
- The amount charged by the provider for each service provided
- Bills in foreign language should be translated to English, foreign currency should be converted to American dollars
- Original bills and receipts required for all services
- Keep a copy of your bills and claim for your records
- Provider’s signature is required
• A completed claim form. Please be sure to accurately complete all sections of the claim form. Always use one claim form per patient.
• When another insurance carrier (including Medicare) is paying your claim first, please submit a copy of their payment statement with your claim. These statements are sometimes called “Explanation of Benefits,” “Summary of Benefits,” “Explanation of Medicare Benefits.”
BILLS FOR THE FOLLOWING SERVICES SHOULD INCLUDE THIS ADDITIONAL INFORMATION
Office Visits: Type of visit (brief, intermediate, extended, etc.)
Private Duty Nursing: Dates and shifts worked, amount charged for each shift, prescribing Doctor’s name and degree, and registration # of nurse.
Durable Medical Equipment: (wheelchair, respirator, oxygen, etc.) Include the full purchase price of any rented equipment. A letter of medical necessity from your physician must be submitted with the claim.
X-rays: Type of x-ray (chest, legs, etc.)
Blood Charges: Include the number of pints received, charges for each, and the number of pints replaced by donors. Indicate whether bill is for whole blood, plasma or derivatives.
General Anesthesia: The length of time (in minutes) the patient was under general anesthesia must appear on the bill.
Accidental Injury Claims: Must indicate the date on which the accident occurred.
Members of the Preferred Provider Option (PPO), Exclusive Provider Organization (EPO) and Point of Service (POS) – Note: Must have pre-authorization on file after the sixth visit for outpatient physical therapy, occupational therapy and after first visit for speech therapy. See your benefit booklet, section: Managed Care Authorization Program for more information.
