The Massachusetts Claim Form is a document used by individuals to submit claims for healthcare services when their provider does not directly send a claim to the local Blue Cross Blue Shield plan. It requires specific information about both the subscriber and the patient, as well as an itemized bill from the healthcare provider. To begin the process, fill out the form by clicking the button below.
The Massachusetts Claim Form is an essential tool for members seeking reimbursement for healthcare services when their provider does not submit a claim directly to Blue Cross Blue Shield of Massachusetts (BCBSMA). This form requires specific information, including subscriber details, patient information, and the nature of the treatment received. It is crucial to submit a separate claim for each patient and attach an original itemized bill from the healthcare provider, which must include necessary details such as provider credentials, service dates, and itemized charges. Additionally, the form asks for information about any other insurance coverage the patient may have, which helps determine the processing of the claim. Remember to sign and date the form before mailing it to the designated BCBSMA address. Claims typically take up to 30 days to process, so it's important to keep a copy of all submitted documents for your records.
SUBSCRIBER CLAIM FORM
Instructions for Submitting Claims
1.Submit a claim only when you are billed for services from a provider that does not directly submit a claim to the local Blue Cross Blue Shield plan.
2.Submit a separate form for each patient.
3.Attach an original itemized bill from your provider (required information & example on the back)
4.Keep a copy of all bills and claim forms submitted (originals will not be returned)
5.Be sure to sign and date the completed form.
6.Mail claim form and all attachments to BCBSMA, P.O. Box 986030, Boston, MA 02298
Subscriber Information
Identification Number (including alpha prefix)
Last Name
First Name
Middle Initial
Address-Number & Street
City
State
Zip Code
Date of Birth (MM/DD/YY)
Employer’s Name
Patient Information
Patient Last Name
Gender:
qMale
qFemale
Patient is:
q Subscriber (contract holder) q Student (age 19 or older) q Other (specify)
q Spouse (to contract holder)q Child (age 18 or younger) q Handicapped Dependent (age 19 or older)
Does the patient have other insurance: q Yes q No
Effective Date:
Medicare Part A (Hospital)
q Yes q No ____/____/_____
Medicare Part B (Medical)
Medicare Part D (Pharmacy)
Other Blue Cross
Blue Shield Membership?
Other Insurance Plan?
Identification Number:
Name and address of other insurance:
Was treatment for:
Accident at work? q Yes q No
Date of accident ____/____/_____
Auto accident? q Yes q No
If yes, name of auto insurance:
Policy Number:
Other accident? q Yes q No
Subscriber Signature:
Date:
Please allow up to 30 days for your claim to process.
Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.
Example of a Complete Itemized Bill
Smith Speech Center
123 Main St.
Boston, MA 12345
To: Joe Smith
Patient Name: Joan Smith
15 Elm St.
Referring Doctor: Dr. John Jones
Anytown, MA 12345
Provider
Jane Johnson,
SLP, CCC
Tax ID/NPI: 99-9999999
Speech-Language Pathologist
Credentials
License # Y777777
Procedure Code(s)
Units
Procedure Description
Date of Service
Amount
92507
1
Speech–Language Therapy
10/5/2008
$72.50
Itemized
Charges
2
11/3/2008
$145.00
Diagnosis Codes: 784.50, 315.31
Total: $290.00
Payments: $290.00
Balance Due: $0.00
Please note that your bill does not need to look exactly like the example above, but MUST contain the following required information:
1.A letterhead from the provider that MUST include all of the following:
–Provider name
–Provider address
–Provider Tax ID/NPI
–Provider credentials, i.e., the initials associated with the educational degrees the provider has earned. Examples include: MD, LICSW, DC, PT, OT, ST
2.Patient’s name
3.Date(s) of service
4.Itemized charges for each date of service and type of service received
5.Procedure codes (HCPCS/Revenue codes) for all services received
6.Diagnosis code(s) for services received
7.Number of Units-this is the number of times a service was performed on a particular date of service. This is required for occupational, physical & speech therapies, anesthesia and chiropractic services.
8.Attach any related claim summaries or Explanation of Medicare Benefit Forms you may have received for these services, including those received from other insurance companies.
9.When submitting a claim for PRESCRIPTION DRUGS, you must submit an itemized receipt from your pharmacy that includes:
–National Drug Code (NDC)
–Name of drug
–Date dispensed
–Quantity dispensed
–Name of prescribing physician
To view processed claims, visit our website http://www.bluecrossma.com/wps/portal/members/. If you have not already registered for Member Central, click Create an Account and follow the directions.
®Registered Marks of the Blue Cross and Blue Shield Association. © 2010 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.
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Once you have gathered all necessary information and documents, you are ready to fill out the Massachusetts Claim form. This process involves providing accurate details about both the subscriber and the patient, as well as attaching an itemized bill from the healthcare provider. After completing the form, you will mail it to the designated address for processing. Allow up to 30 days for your claim to be reviewed.
The Massachusetts Claim Form is designed for subscribers to request reimbursement for medical services when their healthcare provider does not submit a claim directly to Blue Cross Blue Shield of Massachusetts (BCBSMA). This form ensures that claims are processed efficiently and accurately.
This form should be submitted by subscribers who have received services from a provider that does not directly bill BCBSMA. Each claim form must be submitted separately for each patient, ensuring that all necessary information is included for proper processing.
The claim form requires several pieces of information:
In addition, an original itemized bill from the provider must be attached, which includes specific details about the services provided.
The itemized bill must contain the following information:
It is essential that the bill is clear and detailed to avoid delays in processing the claim.
After submitting the claim form and all required attachments, it may take up to 30 days for BCBSMA to process the claim. Subscribers are encouraged to keep copies of all submitted documents for their records.
If the patient has other insurance coverage, this information must be included on the claim form. It is important to provide the name and address of the other insurance company, along with the identification number. This will help ensure that any coordination of benefits is handled correctly.
The completed claim form, along with all necessary attachments, should be mailed to:
BCBSMA P.O. Box 986030 Boston, MA 02298
It is advisable to use a reliable mailing method to ensure that the claim is received in a timely manner.
Not submitting a claim when required. Ensure that you only submit a claim if your provider does not directly send it to the local Blue Cross Blue Shield plan.
Using a single claim form for multiple patients. Each patient requires a separate form, so make sure to fill out one for each individual.
Failing to attach an original itemized bill. This is a crucial step, as the claim cannot be processed without it.
Not keeping a copy of submitted documents. Remember, originals will not be returned, so always retain copies for your records.
Neglecting to sign and date the completed form. This simple step is often overlooked but is essential for processing your claim.
Incorrectly filling out subscriber information. Double-check that your identification number, name, and address are accurate.
Omitting patient information. Ensure that all relevant details about the patient, including their name and date of birth, are included.
Not specifying the patient's relationship to the subscriber. Clearly indicate whether the patient is a spouse, child, or another dependent.
Failing to disclose other insurance coverage. If the patient has other insurance, it’s important to provide that information.
Submitting incomplete or inaccurate itemized bills. Ensure that the bill includes all required information, such as procedure codes and diagnosis codes.
By avoiding these common mistakes, you can help ensure that your claim is processed smoothly and efficiently. Taking the time to double-check your information can save you from delays and frustration.
When submitting a claim using the Massachusetts Claim Form, several additional documents may be required to support your claim. Each of these documents plays a crucial role in ensuring that your claim is processed efficiently and accurately. Below is a list of commonly used forms and documents that you might need to include along with your claim.
Having the right forms and documents ready can significantly speed up the claims process and help avoid delays. Always check with your insurance provider for specific requirements related to your claim submission.
The Massachusetts Claim Form shares similarities with the Health Insurance Claim Form (CMS-1500), widely used in the United States for billing health care services. Both forms require detailed patient information, including demographics and insurance details. They also mandate the submission of itemized bills that outline services rendered, procedure codes, and diagnosis codes. The CMS-1500 is specifically designed for non-institutional providers, making it a direct counterpart to the Massachusetts Claim Form in terms of purpose and content structure.
Another document comparable to the Massachusetts Claim Form is the UB-04 form, commonly used for institutional healthcare billing. Like the Massachusetts Claim Form, the UB-04 requires comprehensive information about the patient, provider, and services provided. While the UB-04 is typically used by hospitals and facilities, both forms emphasize the need for itemized billing and detailed service descriptions. This ensures that insurers have the necessary information to process claims efficiently.
The Explanation of Benefits (EOB) document also resembles the Massachusetts Claim Form in its role within the claims process. While the EOB is not a claim submission form, it provides crucial information after a claim has been processed. It details what services were billed, what the insurance covered, and what the patient is responsible for paying. Both documents aim to clarify the financial aspects of healthcare services, albeit at different stages of the billing cycle.
Additionally, the Medicare Claim Form (CMS-1490S) serves a similar function, particularly for Medicare beneficiaries. This form is used to request reimbursement for services not directly billed to Medicare. Like the Massachusetts Claim Form, it requires detailed information about the patient and the services received. Both forms also necessitate the submission of itemized bills to support the claim, ensuring that all necessary documentation is provided for reimbursement.
The Workers' Compensation Claim Form is another document that shares similarities with the Massachusetts Claim Form. Both forms are used to submit claims for medical services, although the Workers' Compensation Claim Form is specific to injuries sustained at work. Each form requires detailed patient information and documentation of services rendered. The emphasis on itemized billing is consistent across both forms, highlighting the need for transparency in medical billing practices.
Finally, the Dental Claim Form (ADA Form) has a similar structure and purpose. While focused on dental services, it mirrors the Massachusetts Claim Form in its requirement for patient details, provider information, and itemized billing. Both forms aim to facilitate the claims process for insurance reimbursement, ensuring that all necessary information is included for accurate processing.
When filling out the Massachusetts Claim form, it's important to follow specific guidelines to ensure your claim is processed smoothly. Here are six things you should and shouldn't do:
Following these guidelines can help ensure that your claim is processed without unnecessary delays.
Understanding the Massachusetts Claim form can be tricky, and there are several misconceptions that might lead to confusion. Here are six common myths and the truths behind them:
By clearing up these misconceptions, you can navigate the claims process more smoothly and ensure that you receive the benefits you deserve.