Form 110602 - Customer Claim Form (Page 2 of 2) in pdf

INSTRUCTIONS FOR FILING A CLAIM

This form is designed to help you file a claim for health care services received by you or an enrolled family member. If a doctor, hospital,

or other health care provider has already filed a claim directly with Anthem Blue Cross and Blue Shield on your behalf, please do not send

a Customer Claim Form for the same services.

STEP 1. Complete the Insured and Patient Information section.

•Please print or type.

•

All sections must be completed for processing. Make sure to write in your Identification Number as shown on your

ID card including any letters in front of your number.

•Use a separate claim form for each family member and only attach bills for that family member.

•Please provide a daytime telephone number where you can be reached if more information is needed to process this claim.

STEP 2. Complete the Patient’s Condition (diagnosis) and Treatment section.

STEP 3. Review the bills for health care services that you will be sending,

and please keep a copy as bills cannot be returned.

Bills must show an itemized charge for each service the patient received. Each bill must show:

•

The patient’s name.

•

The name, address, and tax identification number of the health care provider.

•

The date of each service, the charge for each service, and a description of each service.

•

The Referral Number for specialist care if your program requires referrals from your Primary Care Physician.

STEP 4. Complete the Attachments section.

If these same services were covered first by another health care plan (the patient’s primary

plan), make sure you have copies of the other plan’s statements showing how each service was paid.

STEP 5. Sign the Authorization.

FOR DRUG CLAIMS PLEASE NOTE

If you do not have a prescription drug card

STEP 6. MAIL YOUR COMPLETED CLAIM TO:

program and are filing for prescriptions

Anthem Blue Cross and Blue Shield

covered under your medical plan, please

P.O. Box 27401

use the section at the bottom of this page.

Richmond, Virginia 23279

If you do have a plastic prescription drug

card, there is a separate form you need to

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc.

use to file claims for prescription charges.

An independent licensee of the Blue Cross and Blue Shield Association.

See your Benefits Administrator for further

® Registered marks Blue Cross and Blue Shield Association.

information.

PRESCRIPTION DRUG CLAIM INFORMATION

If you are not covered under a prescription drug card program, you can use this form to file prescription charges. The front of this form

must be completed. Follow the same instructions above and attach itemized receipts for prescriptions.

If you do not have itemized receipts or a pharmacy print-out signed by the pharmacist, have your pharmacist complete the sections below.

Complete a separate form for each family member.

Patient’s Name _________________________________________________________________________

Date ____________________

Pharmacy Name __________________________________________________________________________________________________

Pharmacy Address _________________________________________

City __________________

State________

Zip___________

PRESCRIPTION DRUG RECORD

Date of

Name and

Prescription

Quantity

Prescribing

Charge

Pharmacist Signature

Purchase

Strength of Drug

Number

Doctor

Total $

__________

Form 110602 - Customer Claim Form Page 2

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