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Claims Administration

Verifying Coverage of a Service To have a procedure or service reviewed for medical necessity prior to the service being performed, the participant’s provider may write a pre-determination letter describing the condition and treatment. The provider’s letter must include the enrollee’s name and identification number, the patient’s name, and pertinent medical information. The letter should be sent to Blue Cross & Blue Shield.

For all inpatient hospital services and the specified diagnostic tests listed in the Medical Management and Utilization Review section, the letter must be sent to Intracorp.

How to File a Medical Claim A claim must be filed before benefits can be determined. The claim must contain all of the information needed by Blue Cross & Blue Shield to process the claim. Network providers have agreed to file claims for participants.

For care received from a non-participating provider, a participant must receive the proper itemized bills from the provider and file a claim. A participant can get a medical claim form from his Human Resources office or from Blue Cross & Blue Shield. The form must be completed in its entirety to avoid delays in processing. Completed medical claim forms must be mailed to Blue Cross & Blue Shield.

  • If another coverage is primary, the claim must be filed with that plan first. Once an explanation of benefits (EOB) from the other plan has been received, the claim must be filed with Blue Cross & Blue Shield. The claim must be filed with a copy of the other plan’s EOB. If the other plan’s EOB is not attached, the claim will be denied until the information is received.

  • If Medicare is primary, the claim must be filed with Medicare first. Once an explanation of Medicare benefits has been received, the claim must be filed with Blue Cross & Blue Shield. The claim must be filed with a copy of the explanation of Medicare benefits. If the explanation of Medicare benefits is not attached, the claim will be denied until the information is received.

How to File a Prescription Drug Claim If a participant uses a pharmacy that participates in the prescription drug program, there is no claim to file. The participant will pay the applicable deductible and co-payment. The prescription drug deductible and co-payment are the participant’s responsibility and will not be reimbursed under the prescription drug program or the medical program.

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