Edit, Download, and Sign the Member Travel Benefit Form Instructions
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How do I fill this out?
To complete the Member Travel Benefit Form, you need to gather all necessary information related to your travel and medical service. Ensure that all required fields are filled out accurately to avoid any delays in processing your claim. Double-check that you meet all eligibility criteria before submission.
How to fill out the Member Travel Benefit Form Instructions?
1
Gather necessary patient and provider information.
2
Complete all sections of the form accurately.
3
Include itemized travel costs and relevant details.
4
Ensure proper submission within the specified timeline.
5
Keep a copy of the submitted form for your records.
Who needs the Member Travel Benefit Form Instructions?
1
Members seeking reimbursement for out-of-state medical travel.
2
Patients accessing medical services not available locally.
3
Individuals traveling with companions for medical care.
4
Anyone advised by their provider to seek services in another state.
5
Claimants wanting to ensure compliance with their plan requirements.
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Open the PDF document in PrintFriendly.
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Click on the text to edit any required fields.
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Make your changes and ensure all information is correct.
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Review the entire document for accuracy.
5
Download or print the edited document for submission.
What are the instructions for submitting this form?
To submit the Member Travel Benefit Form, mail it to Blue Cross and Blue Shield of North Carolina at P.O. Box 35, Durham, NC 27702 or fax it to 1-866-990-1385. Ensure all fields are complete and accurate before submission. It is advisable to keep a copy for your records and follow up with the claims department to confirm receipt of your form.
What are the important dates for this form in 2024 and 2025?
For forms submitted in 2024 and 2025, it's crucial to file within 18 months after receiving medical services. Be aware of any updates to your plan’s travel benefit criteria that may arise each year. Regularly check your plan documents for deadlines and specific filing instructions.
What is the purpose of this form?
The purpose of the Member Travel Benefit Form is to facilitate claims for reimbursement of travel expenses related to covered out-of-state medical services. This form ensures that members who travel for necessary medical care can receive the benefits they are entitled to under their health plans. It helps streamline the process and provides necessary documentation for claims submission.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Details about the patient including the subscriber number, name, and contact information.
- 2. Mailing Information: Address of the subscriber for correspondence related to the claim.
- 3. Itemized Travel Costs: Includes detailed costs related to travel such as hotel, mileage, and transportation expenses.
- 4. Travel Benefit Attestation: A declaration confirming that the information provided is correct and meets the plan criteria.
- 5. Submitted Form Information: Instructions on where to send the completed form for processing.
What happens if I fail to submit this form?
Failure to submit this form may result in denial of reimbursement for your travel expenses. Claims filed after the 18-month deadline will not be processed. It is essential to ensure accurate and timely submission to avoid these issues.
- Claim Denial: If the form is not submitted within the specified timeframe, you may lose your right to reimbursement.
- Incomplete Information: Errors or omissions in the form may lead to delays and potential denial of the claim.
- Noncompliance with Plan Requirements: Not following the guidelines set forth by your plan can render the claim invalid.
How do I know when to use this form?
- 1. Out-of-State Medical Services: File this form when traveling for medical services that are covered by your plan.
- 2. Authorized Treatments: Use the form for services that require prior authorization according to your plan.
- 3. Emergency Medical Travel: In cases where urgent care requires travel outside your state, submit this form for reimbursement.
Frequently Asked Questions
How do I submit the Member Travel Benefit Form?
You can submit the form via mail to the specified address or fax it to the provided number.
What should I do if my claim is denied?
Contact customer service for assistance and inquire about the reconsideration process.
How long do I have to file a claim?
Claims must be submitted within 18 months from the date services were received.
Can I use this form for dental claims?
No, this form is only for covered and authorized travel expenses for medical claims.
What details do I need to provide on the form?
You’ll need patient information, travel costs, and details about the medical service received.
Is there a deadline for completing this form?
Yes, ensure it is submitted within the 18-month filing timeframe.
Do I need to provide proof of travel expenses?
Yes, include itemized costs related to your travel.
Will Blue Cross NC notify me about my claim status?
Yes, you will receive updates regarding the processing of your claim.
Can I appeal a denied travel benefit claim?
Yes, you can request reconsideration of a denied claim after the medical claim is processed.
What if I've changed my address?
Contact customer service to update your information before submitting your claim.
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