Sample ID card and description of terms
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This information is used by physicians and providers.
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Member services numbers and addresses to submit claims.
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Member name – your nameb
Member ID numberc
PCP/SPC – indicates the primary carephysician (PCP)/ specialist (SPC) office visit copays
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ER – indicates emergency room(ER) copay
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Group# and Plan – shows type ofcoverage
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Effective date – the date you becamecovered by our plan
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This information is required bypharmacies to electronically bill prescriptions.
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Providers: Please file all claims with your local BlueCross BlueShield licensee in whose service area the member received services or, when Medicare is primary, file all Medicare claims with Medicare.
California Providers: Call Provider Customer Service to obtain medical and hospital admission prior authorization to avoid reduced or non-payment; Pharmacistscall for prescription processing information. Visit Provider Connection at:
blueshieldca.com/provider.
CA Medical claims to:
Blue Shield of California, P.O. Box 272540, Chico, CA 95927-2540
(800) 642-6155 Member Services
(800) 241-1823 TTY
(877) 263-9952 Mental Health Customer Svc.
(877) 304-0504 NurseHelp 24/7
(800) 985-2405 LifeReferrals 24/7
(800) 810-2583 To locate providers outside of California
(800) 541-6652 CA Provider Customer Service (including hospitals)
(888) 635-8224 Pharmacists Only Blue Shield of California is an independent member of the Blue Shield Association.
Subscriber JOHN DOE ID# XEHJ02388023 Copayments Office $25 Hospital $200 Emergency $100 Group # H12187 Effective 01/01/13 Plan HMO Rx Yes blueshieldca.com
SF HEALTH SERVICE SYSTEM Blue Shield of California
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en d en t M em b er o f t h e B lu e S h ie ld A ssoc ia tio n A 4 576 0 ( 4/ 13 )
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Name of your Personal Physiciank
Name of your medical group or IPAInside right
This information is for you to read in case of emergency, if you are billed in error or need help locating network pharmacies.
MEDICAL GROUP NAME JANE DOE, MD (415) 123-4567 JOHN DOE Effective 01/01/13 JOHN DOE, JR. Effective 01/01/13
A+ gives you the option to self-refer to an Access+ Specialist, subject to certain limitations.
See your Evidence of Coverage for details.
Members:
In case of emergency, call 911 or seek appropriate emergency care. As soon as possible after receiving care, please contact your personal Physician.
It is important to follow the procedures explained in your
Evidence of Coverage booklet. If you have any questions about your benefits, your copayments,or your prescription drug coverage, call Member Services.
Carry this ID card with you at all times and present it to your Personal Physicianwhenever you receive care.
Sample ID card and description of terms
Back left
This information is used by physicians and providers.
Back right
Member services numbers and addresses to submit claims.
i
Address for you to send out-of-networkprescription claims to
Front left
a
Member name – your nameb
Member ID numberc
PCP/SPC – indicates the primary carephysician (PCP)/ specialist (SPC) office visit copays
Note: Refer to your Evidence of Coverage for complete benefit information. The information provided on your ID card is to be used as a quick reference only. Benefits are not limited to this information.
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ER – indicates emergency room(ER) copay
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AMB – indicates ambulance(AMB) copay
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Group No. and Plan – shows typeof coverage
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Card issued – the date your most recentcard was issued to you
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This information is used by pharmacies toelectronically bill prescriptions.
Copayments
PCP/SPC $XX/XX
ER $XXX
AMB $XXX
PhysiCians and Providers: Prior approval: Telephone the physician named on this card prior to treatment in a non-emergency. Provision of routine treatment without prior authorization may result in non-payment.
emergency care: Telephone the physician named on this card as soon as possible after treatment.
note: This card is for identification only. Call the number on the reverse side of this card to verify eligibility.
PhysiCians and Providers:
(877) 654-6500elibility verification Blue Shield of California is an independent member of the Blue Shield Association.
<plan name> (HMO) Member Services
(800) 776-4466 (800) 794-1099TTY Note: This card is for identification only.
submit Medical claims to: Blue Shield 65 Plus P.O. Box 272640 Chico, CA 95927-2640
submit rx claims to:
Blue Shield of California Pharmacy Services P.O. Box 7168 San Francisco, CA 94120-7168 RxBin 012353 RxPCN 01920000 Issuer 80840 CMS H0504-015
Plan <plan name> (hMo)
Group No. Mrd100 Card issued 12/1/12 Plan code Bs1 Member John doe Membership number XeaJ1234567801 blueshieldca.com
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en d en t m em b er o f th e B lu e S h ie ld A ssoc ia tio n A 35 13 8 (1 0/ 12 )
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Name of your primary care physiciank
Name of your medical group orIndependent Practice Association (IPA)
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Hospital name and addressInside right
This information is for you to read in case of emergency, if you are billed in error or need help locating network pharmacies.
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John doe, Md (555) 555-5555 ABC Medical Grp 123 Main St Anytown, CA 00000 HOSPITAl INFORMATION: aBC hospital (555) 555-5555 123 Main St Address line 2 Anytown, CA 00000 (877) 304-0504 NurseHelp 24/7 (800) 855-2881 TTY in an emergency: Call 911 or immediately go to the nearest hospital emergency room for treatment.out-of-area urgent care: If you are outside the health plan area and need medical attention right away for an unforeseen illness or injury, go to the nearest medical facility. Notify Blue Shield 65 Plus or your primary care physician at the time of service or as soon as possible after treatment.
Billing and member services:
Network providers have agreed not to bill Blue Shield 65 Plus members. Contact Member Services if you are billed in error or if you need other assistance with claims or billing.
For information on locating network pharmacies: Call Blue Shield 65 Plus Member Services.
Sample ID card and description of terms
Front
a
Member name – your nameb
Member ID numberc
Card issued – the date your most recentcard was issued to you
d
This information is used by pharmaciesto electronically bill prescriptions.
Back
e
Address for you to send out-of-networkprescription claims to
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Member Services toll-free numberFront
Back
A n in d ep en d en t m em b er o f th e B lu e S h ie ld A ssoc ia tio n A 35 14 5 (1 0/ 12 ) blueshieldca.com RxBin 012353 RxPCN 03510000 RxGrp MRD300 Issuer 80840 CMS S2468-004Plan <plan name> (PDP)
Card issued 12/15/12
Member
John Doe
Membership No.
XEAJ1234567801
Blue Shield of California is an independent member of the Blue Shield Association.
<plan name> (PDP) Member Services
(888) 239-6469Member Services
(888) 239-6482 TTY
Submit Rx claims to:
Blue Shield of California Pharmacy Services P.O. Box 7168 San Francisco, CA 94120-7168
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