The Maryland State Claim Form is a document designed for members of the State Employees Health Plan to submit claims for health services. This form is essential for filing claims with CareFirst BlueCross BlueShield, especially when services are rendered by non-participating providers. To ensure your claims are processed smoothly, it’s important to complete the form accurately and include all necessary documentation.
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The Maryland State Claim form is an essential document for members of the State Employees Health Plan who need to file claims for medical services. This form is specifically designed for use with PPO, POS, and EPO claims, particularly when members receive care from non-participating providers. Key information required on the form includes the subscriber's and patient's legal names, their relationship, and details about the patient's health insurance coverage, including Medicare. Members must provide a comprehensive list of illnesses or injuries for which they are submitting claims, along with relevant treatment dates. The form also prompts users to indicate whether the treatment was related to an injury or an automobile accident. Additional sections require information about other insurance coverage, if applicable, and a certification statement confirming the accuracy of the information provided. To ensure proper processing, it is vital to attach itemized bills that meet specific criteria, such as including the provider's details and descriptions of services rendered. Understanding how to accurately complete the Maryland State Claim form can help streamline the claims process and facilitate timely reimbursement for medical expenses.
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STATE OF MARYLAND EMPLOYEES HEALTH CLAIM FORM
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Subscriber’s Legal Name (Last, First, Middle Initial)
Patient’s Legal Name (Last, First, Middle Initial)
Membership Number
Patient’s Sex
Patient’s Relationship to Subscriber
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2
3
4
q Male
q Female
q Self
q Spouse
q Child
q Other
Subscriber’s Address (Street)
q Check box if NEW address
Patient’s Date of Birth
Month
Date
Year
City
State
Zip Code
Telephone Number
Group Number
IMPORTANT: ALL QUESTIONS MUST BE ANSWERED
List those illnesses for which you are submitting bills and date of first symptom.
Was the treatment a result of an injury?
q Yes q No
Was the treatment a result of an automobile accident?
Description of Accident
Date of Accident
Where Accident Occurred
Was illness(es) or injury(ies) in any way work related?
q Yes
q No
Does patient have Medicare?
Effective Date of Coverage
/
HEALTH INSURANCE
a. Medicare Part A (Hospital Insurance)?
Day
CLAIM NUMBER
b. Medicare Part B (Physician’s Coverage)? q Yes
In addition to coverage under this program, is patient covered under any other insurance providing health care benefits or services?
If “Yes”, please complete:
a. Name of Policy Holder
Relationship to Patient
b. Name of Insuring Co.
c. Policy or Certificate No.
d. Effective Date of Coverage
Month Day
e. Check type of coverage: q Hospital
q Surgical-Medical
q Major Medical
q Other (specify)
f. Check One: I have
q Family q Husband and Wife q Individual q Parent and Child coverage with this carrier.
g. Name and Address of Policy Holder’s Employer
I certify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named above.
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Authorization is hereby given to any hospital, physician, or other provider which participated in any way in my care and treatment to release to CareFirst BlueCross BlueShield any medical information which they in their judgement deem necessary to the adjudication of this claim.
X
SIGNATURE OF SUBSCRIBER
DATE
HAVE YOU ATTACHED YOUR ITEMIZED BILLS?
Administrative Use Only
Provider#
Initials
CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
Mail Administrator
P.O. Box 14115
Lexington, KY 40512-4115
This form is to be used only by members of the State Employees Health Plan to file PPO, POS and EPO claims. While participating providers will bill CareFirst BlueCross BlueShield for services rendered, you may have claims to file yourself if you see non-participating providers.
• A copy of the bill on the provider’s letterhead stationary
IN ORDER FOR YOUR CLAIMS TO BE PROCESSED, THE FOLLOWING INFORMATION MUST BE SUBMITTED
The bill must include:
Provider’s full name, degree, address, phone # and CareFirst BlueCross BlueShield provider number if available.
Patient’s full name
Descriptions of each service or supply
Date of which each service was provided
The provider’s diagnosis, or patient’s chief complaint
The amount charged by the provider for each service provided
Bills in foreign language should be translated to English, foreign currency should be converted to American dollars
Original bills and receipts required for all services
Keep a copy of your bills and claim for your records
Provider’s signature is required
•A completed claim form. Please be sure to accurately complete all sections of the claim form. Always use one claim form per patient.
•When another insurance carrier (including Medicare) is paying your claim first, please submit a copy of their payment statement with your claim. These statements are sometimes called “Explanation of Benefits,” “Summary of Benefits,” “Explanation of Medicare Benefits.”
BILLS FOR THE FOLLOWING SERVICES SHOULD INCLUDE THIS ADDITIONAL INFORMATION
Office Visits:
Type of visit (brief, intermediate, extended, etc.)
Private Duty Nursing:
Dates and shifts worked, amount charged for each shift, prescribing Doctor’s name and degree,
and registration # of nurse.
Durable Medical Equipment:
Include the full purchase price of any rented equipment. A letter of medical necessity from your
(wheelchair, respirator, oxygen, etc.)
physician must be submitted with the claim.
X-rays:
Type of x-ray (chest, legs, etc.)
Blood Charges:
Include the number of pints received, charges for each, and the number of pints replaced by
donors. Indicate whether bill is for whole blood, plasma or derivatives.
General Anesthesia:
The length of time (in minutes) the patient was under general anesthesia must appear on the bill.
Accidental Injury Claims:
Must indicate the date on which the accident occurred.
Members of the Preferred Provider Option (PPO), Exclusive Provider Organization (EPO) and Point of Service (POS) – Note: Must have pre- authorization on file after the sixth visit for outpatient physical therapy, occupational therapy and after first visit for speech therapy. See your benefit booklet, section: Managed Care Authorization Program for more information.
CareFirst BlueCross BlueShield State of Maryland Member Service
1-800-225-0131
Access our website at www.carefirst.com/statemd
Understanding the Maryland State Claim form can be challenging, and several misconceptions often arise. Here are ten common misunderstandings, along with clarifications to help you navigate the process more effectively.
By addressing these misconceptions, you can approach the Maryland State Claim form with greater confidence and clarity.
Filling out the Maryland State Claim form can be a straightforward process, but many people make mistakes that can delay their claims. One common error is failing to provide complete information in the required fields. The form asks for specific details, such as the subscriber's and patient's legal names, membership number, and the patient's date of birth. Omitting any of this information can lead to processing delays. It’s essential to double-check that every question is answered fully before submitting the form.
Another mistake often made is not including the necessary documentation. Claims require itemized bills that detail the services provided, including the provider’s name, address, and the specific charges. Some individuals neglect to attach these bills or submit incomplete documentation. Without the proper paperwork, the claim may be denied or returned for further information, which prolongs the claims process.
People also frequently misidentify the relationship between the patient and the subscriber. The form requires that you accurately indicate whether the patient is a self, spouse, child, or other. Incorrectly stating this relationship can lead to confusion and could result in the claim being processed under the wrong policy. Always ensure that this section is filled out correctly to avoid unnecessary complications.
Lastly, many individuals overlook the importance of signatures and dates. The claim form must be signed by the subscriber, and the date of signature is equally important. Submitting a form without a signature or with an incorrect date can invalidate the claim. Make it a habit to review the form thoroughly before sending it off, ensuring that all required signatures are present and dated correctly.
When filling out the Maryland State Claim form, keep these key takeaways in mind:
When filing a claim with the Maryland State Claim form, you may need to include additional documents to ensure your claim is processed smoothly. Each of these documents serves a specific purpose and helps provide the necessary information for your claim. Below is a list of commonly required forms and documents.
Including these documents with your Maryland State Claim form can significantly streamline the claims process. Always double-check that you have all necessary paperwork before submission to avoid delays. Being thorough and organized will help ensure you receive the benefits you are entitled to.
The Maryland State Claim form shares similarities with the Health Insurance Claim Form (CMS-1500), which is commonly used by healthcare providers to bill Medicare and Medicaid. Both forms require detailed patient information, including the patient’s name, date of birth, and insurance details. They also necessitate a description of the services rendered and the corresponding charges. The CMS-1500 form is structured to ensure that all necessary information is provided for reimbursement, much like the Maryland State Claim form, which also emphasizes the importance of accurate and complete information for processing claims.
Another document similar to the Maryland State Claim form is the UB-04 form, often used by hospitals and healthcare facilities for billing institutional services. Like the Maryland form, the UB-04 requires comprehensive information about the patient and the services provided. Both forms include sections for diagnosis codes and procedure codes, ensuring that the billing is aligned with the services rendered. The UB-04 is specifically designed for institutional claims, whereas the Maryland State Claim form is tailored for individual health claims, but both serve the fundamental purpose of facilitating reimbursement for healthcare services.
The Explanation of Benefits (EOB) statement is also comparable to the Maryland State Claim form in that it outlines the services provided, the amount billed, and the insurance company's payment decisions. While the Maryland form is used to submit claims, the EOB is issued by the insurance company after a claim is processed. Both documents require clear identification of the patient and details of the treatment received, ensuring transparency in the claims process. The EOB helps patients understand their financial responsibility, similar to how the Maryland form helps initiate the claims process.
The Workers' Compensation Claim form is another document that aligns with the Maryland State Claim form, particularly in cases where treatment is related to work-related injuries. Both forms gather information about the patient, the nature of the injury, and the treatment received. They also require details about the employer and insurance coverage. The Workers' Compensation Claim form specifically addresses claims related to workplace injuries, while the Maryland State Claim form is broader, covering various health claims, but both are essential for ensuring that patients receive the benefits they are entitled to.
Lastly, the Dental Claim Form is similar to the Maryland State Claim form in that it is used to submit claims for dental services. Both forms require patient information, details about the services provided, and the associated costs. The Dental Claim Form focuses on dental procedures, while the Maryland State Claim form encompasses a wider range of health services. However, both documents serve the same purpose of facilitating reimbursement for services rendered, ensuring that patients can access the benefits of their insurance coverage.