Member Submitted Claim Form - Premera Blue Cross
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1
2P .O. Box 91059
Member Submitted Claim Form
Seattle, WA 98111-9159
This form is to be used for medical, vision, and dental claims where you incurred expenses from a provider who did not bill the plan directly.
Do not use this form for prescription reimbursement. Please use the Prescription Drug Reimbursement Form (for primary prescription
claim submission) or the Secondary Insurance Prescription Drug Claim Form.
See instructions on other side for additional information to complete your claim.
1. Patient / Member
Prefix and ID number (see ID card)
Group number (see ID card)
Patient name (first, middle, last)
Date of birth (month/day/year)
Address
City
State
ZIP
Home phone number
Work or alternate phone number
Subscriber name (first, middle, last)
Does the patient have coverage from any other health plan?
No, skip to section 2
Yes, please attach the Explanation of Benefits (EOB) statement from the primary plan with this claim, and complete the following information.
Name of other health plan
ID number or policy number of other health plan Phone number of other health plan
NOTE: You must submit an itemized bill or your claim will be returned.
2. Claim Details
Have the charges been paid in full?
No
Yes, please attach proof of payment in full with your itemized bill.
In what setting were these services performed?
Inpatient hospital
Outpatient hospital
Office/clinic
Surgery center
Skilled nursing facility
Home
Other:
NOTE: You must submit an itemized bill or your claim will be returned.
3. International Claim
Is this claim for expenses incurred outside the U.S.A.?
No, skip to section 4
Yes, please attach an itemized bill, available medical records, and complete this section.
Name of provider
Type of provider
Country of service
City of service
Date of service
Hospital
Lab
Office
X-ray
Diagnosis (describe illness and symptoms requiring treatment)
Charges
Currency used
4. Accident / Injury
Is this claim due to an accidental injury?
Date of accident
Where did the accident occur?
No, skip to section 5
Yes, complete this section
Home
Work
School
Auto
Other:
How did the accident happen?
Description of injury
5. Signature
To be accepted, this form must be fully completed (as appropriate to the claim being submitted), signed, and have an itemized bill attached.
Mail to: Premera Blue Cross, P.O. Box 91059, Seattle, WA 98111-9159
Patient signature (or legal guardian if patient cannot legally consent to services)
Relationship to patient
Date (month/day/year)
Self
Other:
Please note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance benefits.
008755 (09-2015)
An Independent Licensee of the Blue Cross Blue Shield Association
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