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How do I fill this out?
To fill out this form, start by completing the patient and subscriber information. Next, attach itemized bills related to the services received. Lastly, sign and submit the form to Regence BlueShield.
How to fill out the Uniform Medical Plan Claim Submission Form?
1
Complete the patient and subscriber information.
2
Attach itemized bills for services received.
3
Sign the completed form as indicated.
4
Submit the form via mail or fax.
5
Retain copies of everything for your records.
Who needs the Uniform Medical Plan Claim Submission Form?
1
Individuals using non-network medical providers need this form to claim costs.
2
Dependents of insured members must submit their own claims with this form.
3
Subscribers who experience a service delay or have additional claims.
4
Users who have submitted itemized bills for reimbursement.
5
Any user managing medical expenses covered by the Uniform Medical Plan.
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1
Open the PDF in PrintFriendly.
2
Click on the section you want to edit.
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Review all modifications before finalizing.
5
Download the edited PDF for submission.
What are the instructions for submitting this form?
To submit this form, complete it in its entirety and attach all necessary documentation, including itemized bills. Mail to Regence BlueShield at PO Box 1106, Lewiston, ID 83501, or fax it to 1-877-357-3418. For questions regarding your submission, you can contact PEBB Customer Service at 1-888-849-3681.
What are the important dates for this form in 2024 and 2025?
Important dates for the Uniform Medical Plan may include changes in policy effective dates, renewal dates for plan members, and submission deadlines for previous service claims, specifically stating that claims need to be submitted within one year from the date of service.
What is the purpose of this form?
The purpose of this form is to facilitate reimbursement requests for services provided by non-network healthcare providers. By using this form, members of the Uniform Medical Plan can accurately report their medical expenses incurred outside of their network, ensuring they receive the benefits entitled to them. This claim form provides a streamlined process for managing healthcare costs, enhancing the overall customer experience.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's Information: Includes details like name, date of birth, and relationship to subscriber.
- 2. Subscriber's Information: Captures the name and identification number of the subscriber.
- 3. Claim Details: Lists all relevant medical services, charges, and diagnosis.
- 4. Additional Insurance: Space to mention any other insurance coverage that may affect the claim.
- 5. Signature Section: Where the subscriber must sign to confirm accuracy and submission.
What happens if I fail to submit this form?
Failing to submit this form will result in an inability to claim reimbursement for eligible medical expenses. Without a properly filled-out claim form, expenses may go unpaid, impacting financial balance.
- Delayed Reimbursement: Claims cannot be processed without a submitted form.
- Financial Strain: Un-reimbursed expenses could impact your budget.
- Loss of Eligibility: Submissions must adhere to timelines to avoid losing benefits.
How do I know when to use this form?
- 1. Receiving Non-Network Care: When visiting providers not contracted with your health plan.
- 2. Claiming Out-of-Pocket Expenses: When you pay for services directly and seek reimbursement.
- 3. Claiming Medical Supplies: Submitting claims for supplies or prescriptions obtained out-of-network.
Frequently Asked Questions
How do I fill out the claim form?
Input patient details, attach bills, sign, and submit.
What services are eligible for claims?
Any medical services received from non-network providers.
How can I submit my claim?
Submit via mail or fax to Regence BlueShield.
Can I edit the PDF form?
Yes, use PrintFriendly to edit before downloading.
Is there a time limit for submitting claims?
Yes, claims must be submitted within one year of service.
What if I forgot to sign the document?
Your claim will not be processed without a signature.
Are there any fees for submitting claims?
No, there are no fees for submitting claims using this form.
How can I check the status of my claim?
Contact Regence Customer Service for claim status inquiries.
What happens if my claim is denied?
You will receive a notification with reasons for denial.
Can I submit claims for multiple family members at once?
No, complete a separate form for each family member.
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