Common use of How to File Insurance Claims for Benefits Clause in Contracts

How to File 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: United Concordia Dental Claims Department P.O. Box 69441 Harrisburg, 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 his enrollment form.) The ID card also lists the Member’s contract number (ID #). This number is the identification to the Member’s membership records and should be provided to UCD 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: an appropriate Claim form is used this contract number (ID #) shown on the form is identical to the number on the ID card the patient's date of birth is listed the patient's relationship to the Subscriber is correctly stated all charges are itemized, whether on the Claim form or on the attached statement the date of service or date of treatment is correct the Provider includes a diagnosis and procedure code for each service/treatment rendered (the diagnosis code pointers must be consistent with the Claim form) the Claim is completed and signed by the Member and the Provider.

How to File Insurance Claims for Benefits. The Company Claims Administrator and most Providers have entered into agreements that eliminate the need for a Member Plan Participant to personally file a Claim for Benefits. Participating Providers will file Claims for Members Plan Participants either by mail or electronically. In certain situations, the Provider may request the Member Plan Participant to file the Claim. If the MemberPlan Participant’s Provider does request the Member Plan Participant to file directly with the CompanyClaims Administrator, the following information will help the Member Plan Participant in correctly completing the Claim form. If You need to file a paper claimClaim, send it to: United Concordia Dental Claims Department P.O. Box 69441 Harrisburg, PA 17106-9441 The MemberPlan Participant’s Blue Cross and Blue Shield Identification Card (ID card) card shows the way the name of the Subscriber Employee (Member Plan Participant of the Group) appears on the Company Claims Administrator’s records. (If the Member Plan Participant has Dependent coverage, the name(s) are recorded as shown on the Member wrote them on his enrollment forminformation the Plan received.) The ID card also lists the MemberPlan Participant’s contract number (ID #). This number is the identification to the MemberPlan Participant’s membership records and should be provided to UCD the 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 MemberPlan Participant’s Claims, the Member Plan Participant must be sure that: an appropriate Claim form is used this contract number (ID #) shown on the form is identical to the number on the ID card the patient's name and date of birth is listed the patient's relationship to the Subscriber Employee is correctly stated all charges are itemized, whether on the Claim form or on the attached statement the date of service or date of treatment is correct the Provider includes a diagnosis diagnosis, procedure code, and procedure code total minutes (anesthesia professional fee) for each service/treatment rendered (the diagnosis code pointers must be consistent with the Claim form) the Provider’s name, address and tax ID number the Claim is completed and signed by the Member Plan Participant and the ProviderPro vider.

How to File Insurance Claims for Benefits. The Company and most Participating 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 electronicallyelectronically and the Participating Provider normally will be reimbursed directly. 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 In certain situations, and only when permitted by the Company, a Member may consent to file allow a paper claim, send it to: United Concordia Dental Claims Department P.O. Box 69441 Harrisburg, PA 17106-9441 Non- Participating Provider to be reimbursed directly. 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 his the enrollment form.) The ID card also lists the Member’s contract number (ID #). This number is the identification to the Member’s membership records and should be provided to UCD 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)Employee Member. 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: an appropriate Claim form is used this contract number (ID #) shown on the form is identical to the number on the ID card the patient's date of birth is listed the patient's relationship to the Subscriber is correctly stated all charges are itemized, whether on the Claim form or on the attached statement the date of service or date of treatment is correct the Provider includes a diagnosis and procedure code for each service/treatment rendered (the diagnosis code pointers must be consistent with the Claim form) the Claim is completed and signed by the Member and the Provider.

How to File 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: United Concordia Dental Claims Department P.O. Box 69441 HarrisburgX.X. Xxx 00000 Xxxxxxxxxx, PA 17106XX 00000-9441 0000 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 his enrollment form.) The ID card also lists the Member’s contract number (ID #). This number is the identification to the Member’s membership records and should be provided to UCD 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: an appropriate Claim form is used this contract number (ID #) shown on the form is identical to the number on the ID card the patient's date of birth is listed the patient's relationship to the Subscriber is correctly stated all charges are itemized, whether on the Claim form or on the attached statement the date of service or date of treatment is correct the Provider includes a diagnosis and procedure code for each service/treatment rendered (the diagnosis code pointers must be consistent with the Claim form) the Claim is completed and signed by the Member and the Provider.

How to File 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: United Concordia Dental Claims Department P.O. Box X. X. Xxx 69441 Harrisburg, 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 his enrollment form.) The ID card also lists the Member’s contract number (ID #). This number is the identification to the Member’s membership records and should be provided to UCD 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: an appropriate Claim form is used this contract number (ID #) shown on the form is identical to the number on the ID card the patient's date of birth is listed the patient's relationship to the Subscriber is correctly stated all charges are itemized, whether on the Claim form or on the attached statement the date of service or date of treatment is correct the Provider includes a diagnosis and procedure code for each service/treatment rendered (the diagnosis code pointers must be consistent with the Claim form) the Claim is completed and signed by the Member and the Provider.