Common use of Prescription Drug Claims Clause in Contracts

Prescription Drug Claims. If You have Prescription Drug coverage, You pay for the drugs when You buy them and then You must file Claims to receive Benefits. To file, You must use the Prescription Drug Claim Form and have Your pharmacist sign it (or an attachment that We accept). After the form is completed, send it to Us at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029 When You receive other medical services (For instance, when You go to clinics or Provider offices), ask if the Provider has contracted with Blue Cross and Blue Shield of Louisiana. If so, this Provider will file Your Claim with Us. When Your Provider files on Your behalf, We will pay Your Provider based on Our contracted terms. However, in some instances, Providers may ask You to pay directly. If this occurs, get an itemized copy of the bill, be sure the Claim form is complete and correctly notes the following information: ◼ The Contract number (ID #) on the form must be the same as the number on Your ID card.‌ ◼ The patient’s full name. ◼ The patient’s date of birth. ◼ The patient’s relationship to the Subscriber. ◼ Dates of service ◼ Name and address of Provider of service. ◼ Diagnosis code ◼ Description of and procedure code for service ◼ The itemized charges for each procedure or service. Note: Statements, canceled checks, payment receipts and balance forward bills do not replace itemized bills. ◼ The Provider must mark the statement or Claim form PAID. Send completed Claim form to: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029

Prescription Drug Claims. If You have Prescription Drug coverage, You pay for the drugs when You buy them and then You must file Claims to receive Benefits. To file, You must use the Prescription Drug Claim Form and have Your pharmacist sign it (or an attachment that We accept). After the form is completed, send it to Us at: Blue Cross and Blue Shield of Louisiana P.O. P. O. Box 98029 Baton Rouge, LA 70898-9029 When You receive other medical services (For instance, when You go to clinics or Provider offices), ask if the Provider has contracted with Blue Cross and Blue Shield of Louisiana. If so, this Provider will file Your Claim with Us. When Your Provider files on Your behalf, We will pay Your Provider based on Our contracted terms. However, in some instances, Providers may ask You to pay directly. If this occurs, get an itemized copy of the bill, be sure the Claim form is complete and correctly notes the following information: ◼ The Contract number (ID #) on the form must be the same as the number on Your ID card.‌ card. ◼ The patient’s full name. ◼ The patient’s date of birth. ◼ The patient’s relationship to the Subscriber. ◼ Dates of service ◼ Name and address of Provider of service. ◼ Diagnosis code code‌ ◼ Description of and procedure code for service ◼ The itemized charges for each procedure or service. Note: Statements, canceled checks, payment receipts and balance forward bills do not replace itemized bills. ◼ The Provider must mark the statement or Claim form PAID. Send completed Claim form to: Blue Cross and Blue Shield of Louisiana P.O. P. O. Box 98029 Baton Rouge, LA 98029-9029

Prescription Drug Claims. If You have Prescription Drug coverage, You pay for the drugs when You buy them and then You must file Claims to receive Benefits. To file, You must use the Prescription Drug Claim Form and have Your pharmacist sign it (or an attachment that We accept). After the form is completed, send it to Us at: Blue Cross and Blue Shield of Louisiana P.O. P. O. Box 98029 Baton Rouge, LA 70898-9029 When You receive other medical services (For instance, when You go to clinics or Provider offices), ask if the Provider has contracted with Blue Cross and Blue Shield of Louisiana. If so, this Provider will file Your Claim with Us. When Your Provider files on Your behalf, We will pay Your Provider based on Our contracted terms. However, in some instances, Providers may ask You to pay directly. If this occurs, get an itemized copy of the bill, be sure the Claim form is complete and correctly notes the following information: ◼ The Contract number (ID #) on the form must be the same as the number on Your ID card.‌ card. ◼ The patient’s full name. ◼ The patient’s date of birth. ◼ The patient’s relationship to the Subscriber. ◼ Dates of service ◼ Name and address of Provider of service. ◼ Diagnosis code code‌‌ ◼ Description of and procedure code for service ◼ The itemized charges for each procedure or service. Note: Statements, canceled checks, payment receipts and balance forward bills do not replace itemized bills. ◼ The Provider must mark the statement or Claim form PAID. Send completed Claim form to: Blue Cross and Blue Shield of Louisiana P.O. P. O. Box 98029 Baton Rouge, LA 98029-9029

Prescription Drug Claims. If You have Prescription Drug coverage, You pay for the drugs when You buy them and then You must file Claims to receive Benefits. To file, You must use the Prescription Drug Claim Form and have Your pharmacist sign it (or an attachment that We accept). After the form is completed, send it to Us at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029 When You receive other medical services (For instance, when You go to clinics or Provider offices), ask if the Provider has contracted with Blue Cross and Blue Shield of Louisiana. If so, this Provider will file Your Claim with Us. When Your Provider files on Your behalf, We will pay Your Provider based on Our contracted terms. However, in some instances, Providers may ask You to pay directly. If this occurs, get an itemized copy of the bill, be sure the Claim form is complete and correctly notes the following information: ◼ The Contract number (ID #) on the form must be the same as the number on Your ID card.‌ card. ◼ The patient’s full name. ◼ The patient’s date of birth. ◼ The patient’s relationship to the Subscriber. ◼ Dates of service ◼ Name and address of Provider of service. ◼ Diagnosis code ◼ Description of and procedure code for service ◼ The itemized charges for each procedure or service. Note: Statements, canceled checks, payment receipts and balance forward bills do not replace itemized bills. bills.‌‌ ◼ The Provider must mark the statement or Claim form PAID. Send completed Claim form to: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029

Prescription Drug Claims. If You have Prescription Drug coverage, You pay for the drugs when You buy them and then You must file Claims to receive Benefits. To file, You must use the Prescription Drug Claim Form and have Your pharmacist sign it (or an attachment that We accept). After the form is completed, send it to Us at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029 When You receive other medical services (For instance, when You go to clinics or Provider offices), ask if the Provider has contracted with Blue Cross and Blue Shield of Louisiana. If so, this Provider will file Your Claim with Us. When Your Provider files on Your behalf, We will pay Your Provider based on Our contracted terms. However, in some instances, Providers may ask You to pay directly. If this occurs, get an itemized copy of the bill, be sure the Claim form is complete and correctly notes the following information: ◼ The Contract number (ID #) on the form must be the same as the number on Your ID card.‌ card. ◼ The patient’s full name. ◼ The patient’s date of birth. ◼ The patient’s relationship to the Subscriber. ◼ Dates of service ◼ Name and address of Provider of service. ◼ Diagnosis code ◼ Description of and procedure code for service service‌‌ ◼ The itemized charges for each procedure or service. Note: Statements, canceled checks, payment receipts and balance forward bills do not replace itemized bills. ◼ The Provider must mark the statement or Claim form PAID. Send completed Claim form to: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029

Prescription Drug Claims. If You have Prescription Drug coverage, You pay for the drugs when You buy them and then You must file Claims to receive Benefits. To file, You must use the Prescription Drug Claim Form and have Your pharmacist sign it (or an attachment that We accept). After the form is completed, send it to Us at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029 When You receive other medical services (For instance, when You go to clinics or Provider offices), ask if the Provider has contracted with Blue Cross and Blue Shield of Louisiana. If so, this Provider will file Your Claim with Us. When Your Provider files on Your behalf, We will pay Your Provider based on Our contracted terms. However, in some instances, Providers may ask You to pay directly. If this occurs, get an itemized copy of the bill, be sure the Claim form is complete and correctly notes the following information: ◼  The Contract number (ID #) on the form must be the same as the number on Your ID card.‌ ◼ card.  The patient’s full name. ◼  The patient’s date of birth. ◼  The patient’s relationship to the Subscriber. ◼  Dates of service ◼  Name and address of Provider of service. ◼  Diagnosis code ◼  Description of and procedure code for service ◼ service‌  The itemized charges for each procedure or service. Note: Statements, canceled checks, payment receipts and balance forward bills do not replace itemized bills. ◼  The Provider must mark the statement or Claim form PAID. Send completed Claim form to: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029

Prescription Drug Claims. If You have Prescription Drug coverage, You pay for the drugs when You buy them and then You must file Claims to receive Benefits. To file, You must use the Prescription Drug Claim Form and have Your pharmacist sign it (or an attachment that We accept). After the form is completed, send it to Us at: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 70898-9029 When You receive other medical services (For instance, when You go to clinics or Provider offices), ask if the Provider has contracted with Blue Cross and Blue Shield of Louisiana. If so, this Provider will file Your Claim with Us. When Your Provider files on Your behalf, We will pay Your Provider based on Our contracted terms. However, in some instances, Providers may ask You to pay directly. If this occurs, get an itemized copy of the bill, be sure the Claim form is complete and correctly notes the following information: ◼  The Contract number (ID #) on the form must be the same as the number on Your ID card.‌ ◼ card.  The patient’s full name. ◼  The patient’s date of birth. ◼  The patient’s relationship to the Subscriber. ◼  Dates of service ◼  Name and address of Provider of service. ◼  Diagnosis code ◼  Description of and procedure code for service ◼  The itemized charges for each procedure or service. Note: Statements, canceled checks, payment receipts and balance forward bills do not replace itemized bills. ◼ bills.‌‌  The Provider must mark the statement or Claim form PAID. Send completed Claim form to: Blue Cross and Blue Shield of Louisiana P.O. Box 98029 Baton Rouge, LA 98029-9029