Common use of FILING INSURANCE CLAIMS FOR BENEFITS Clause in Contracts

FILING INSURANCE CLAIMS FOR BENEFITS. The Company and most Providers have entered into agreements that eliminate the need for a Member to personally file a Claim for Benefits. Participating Providers will file Claims for Members either by mail or electronically. In certain situations, the Provider may request the Member to file the Claim. If the Member’s Provider does request the Member to file directly with the Company, the following information will help the Member in correctly completing the Claim form. If You need to file a paper claim, send it to: Xxxxx Vision P.O. Box 1525 Latham, NY 12110 The Member’s Blue Cross and Blue Shield Identification Card (ID card) shows the way the name of the Subscriber (Member of the Group) appears on the Company records. (If the Member has Dependent coverage, the name(s) are recorded as the Member wrote them on the enrollment form.) The ID card also lists the Member’s Identification number (ID #). This number is the identification to the Member’s membership records and should be provided to Xxxxx Vision each time a Claim is filed. If the Subscriber completes the Claim form and this is a Group plan, remember: the Subscriber is the employee Member (if this is a group contract). If the Subscriber is the patient, the relationship is SELF. If the Subscriber’s wife or husband is the patient, the relationship is SPOUSE. To assist in promptly handling the Member’s Claims, the Member must be sure that:

FILING INSURANCE CLAIMS FOR BENEFITS. ‌ The Company and most Providers have entered into agreements that eliminate the need for a Member to personally file a Claim for Benefits. Participating Providers will file Claims for Members either by mail or electronically. In certain situations, the Provider may request the Member to file the Claim. If the Member’s Provider does request the Member to file directly with the Company, the following information will help the Member in correctly completing the Claim form. If You need to file a paper claim, send it to: Xxxxx Vision P.O. Box 1525 Latham, NY 12110 The Member’s Blue Cross and Blue Shield Identification Card (ID card) shows the way the name of the Subscriber (Member of the Group) appears on the Company records. (If the Member has Dependent coverage, the name(s) are recorded as the Member wrote them on the enrollment form.) The ID card also lists the Member’s Identification number (ID #). This number is the identification to the Member’s membership records and should be provided to Xxxxx Vision each time a Claim is filed. If the Subscriber completes the Claim form and this is a Group plan, remember: the Subscriber is the employee Member (if this is a group contract). If the Subscriber is the patient, the relationship is SELF. If the Subscriber’s wife or husband is the patient, the relationship is SPOUSE. To assist in promptly handling the Member’s Claims, the Member must be sure that:

FILING INSURANCE CLAIMS FOR BENEFITS. ‌ The Company and most Providers have entered into agreements that eliminate the need for a Member to personally file a Claim for Benefits. Participating Providers will file Claims for Members either by mail or electronically. In certain situations, the Provider may request the Member to file the Claim. If the Member’s Provider does request the Member to file directly with the Company, the following information will help the Member in correctly completing the Claim form. If You need to file a paper claim, send it to: Xxxxx Vision United Concordia Dental Claims Department P.O. Box 1525 Latham69441 Harrisburg, NY 12110 PA 17106-9441 The Member’s Blue Cross and Blue Shield Identification Card (ID card) shows the way the name of the Subscriber (Member of the Group) appears on the Company records. (If the Member has Dependent coverage, the name(s) are recorded as the Member wrote them on the his enrollment form.) The ID card also lists the Member’s Identification contract number (ID #). This number is the identification to the Member’s membership records and should be provided to Xxxxx Vision Claims Administrator each time a Claim is filed. If the Subscriber completes the Claim form and this is a Group plan, remember: the Subscriber is the employee Member (if this is a group contract). If the Subscriber is the patient, the relationship is SELF. If the Subscriber’s wife or husband is the patient, the relationship is SPOUSE. To assist in promptly handling the Member’s Claims, the Member must be sure that:

FILING INSURANCE CLAIMS FOR BENEFITS. The Company and most Providers have entered into agreements that eliminate the need for a Member to personally file a Claim for Benefits. Participating Providers will file Claims for Members either by mail or electronically. In certain situations, the Provider may request the Member to file the Claim. If the Member’s Provider does request the Member to file directly with the Company, the following information will help the Member in correctly completing the Claim form. If You need to file a paper claim, send it to: Xxxxx Vision United Concordia Dental Claims Department P.O. Box 1525 Latham69441 Harrisburg, NY 12110 PA 17106-9441 The Member’s Blue Cross and Blue Shield Identification Card (ID card) shows the way the name of the Subscriber (Member of the Group) appears on the Company records. (If the Member has Dependent coverage, the name(s) are recorded as the Member wrote them on the his enrollment form.) The ID card also lists the Member’s Identification contract number (ID #). This number is the identification to the Member’s membership records and should be provided to Xxxxx Vision Claims Administrator each time a Claim is filed. If the Subscriber completes the Claim form and this is a Group plan, remember: the Subscriber is the employee Member (if this is a group contract). If the Subscriber is the patient, the relationship is SELF. If the Subscriber’s wife or husband is the patient, the relationship is SPOUSE. To assist in promptly handling the Member’s Claims, the Member must be sure that: