DENTAL PROVIDER MANUAL INCLUDING COVERAGE GUIDELINES FOR:

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D

ENTAL

P

ROVIDER

M

ANUAL

INCLUDING COVERAGE GUIDELINES FOR:

Dental Basic

Dental Plus

Dental Blue

Binghamton Dental

HMO 100 / 100 Plus

FEP Dental

National Accounts

Baille Lumber Goodyear

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T

ABLE OF

C

ONTENTS

DENTAL PRODUCT OVERVIEW --- 4

DENTAL PLUS--- 4

DENTAL BASIC--- 4

HMO100/100PLUS--- 4

FEDERAL EMPLOYEE PROGRAM--- 5

SELF INSURED /ASO(ADMINISTRATIVE SERVICES ONLY) --- 5

DENTAL BLUE III,HIGH &LOW OPTIONS--- 5

PRE-TREATMENT ESTIMATES--- 5

CLAIMS AND INQUIRIES--- 5

DENTAL PROVIDER SERVICE--- 6

NETWORK MANAGEMENT DEPARTMENT--- 6

PROVIDER SERVICE CALL CENTER--- 6

DENTAL PROVIDER SERVICE PHONE LIST--- 6

Network Management--- 6

Provider Call Centers --- 6

FEP Dental Program --- 6

MEMBER SERVICES PHONE LIST--- 6

Buffalo and Western New York --- 6

Major and National Account Services --- 6

Olean and Jamestown Satellite Offices --- 6

SUPPLIES--- 7

UTILIZATION MANAGEMENT AND PREDETERMINATION OF BENEFITS--- 7

PREDETERMINATION--- 7

SUPPORTING DOCUMENTATION--- 8

BILL YOUR USUAL AND CUSTOMARY CHARGE--- 8

DENTAL PRODUCTS --- 9

DENTAL PLUS--- 9

PRODUCT INFORMATION--- 9

No Deductible: --- 9

May Be Subject to Deductible: --- 9

DENTAL PLUS RISK AND COMPENSATION--- 9

DENTAL BASIC--- 10

Administrative Guidelines--- 10

RISK AND COMPENSATION--- 10

DENTAL BASIC BENEFITS--- 10

Basic Contract--- 10

ADDITIONAL DENTAL BASIC BENEFITS--- 10

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Rider B - Prosthetic Services--- 10

Rider C - Periodontic Services--- 11

Rider D - Orthodontic Services --- 11

Rider 8 - Dependent Coverage to Age 23 --- 11

MAXIMUMS--- 11

DEDUCTIBLES--- 11

HMO100/100PLUS--- 13

SELF INSURED /ASO(ADMINISTRATIVE SERVICES ONLY) --- 14

FEPDENTAL --- 16

PROVIDER REIMBURSEMENT AND BILLING GUIDELINES--- 17

EXPLANATION OF CHECK/SUMMARY AND PAYMENT NOTICE --- 17

CHECK/SUMMARY FORM--- 17

PAYMENT NOTICE--- 17

Payment Notice Field Descriptions: --- 17

BILLING TIPS--- 18

TIMELY FILING--- 18

COORDINATION OF BENEFITS--- 18

SERVICES STARTED PRIOR TO COVERAGE DATE--- 19

DENIAL:INVALID TOOTH NUMBER FOR PROCEDURE--- 19

INFECTION CONTROL ALLOWANCE--- 19

PROVIDER CLAIM INQUIRY--- 19

PROVIDER CLAIM INQUIRY FORM--- 20

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D

ENTAL

P

RODUCT

O

VERVIEW

Dental Plus

• Dental Plus fee schedule • 10% Withhold

• $50 / $150 Single/Family deductibles may apply to all services except diagnostic and preventive

• A $1,000 per member per year maximum applies to all services, except orthodontic • A $1,000 lifetime member maximum applies for orthodontic

• Members cannot be billed for withhold or variance amounts (difference between provider charge and allowance)

• Services rendered by non-participating in area providers are not eligible for payment through Dental 1018

Preventive and Diagnostic 100%

Sealants and space maintainers, restorative, periodontic,

endodontic and oral surgery 80%

Prosthodontics 50%

Orthodontic for covered contracts 50%

Dental Basic

• Dental Basic fee schedule

• Same administrative guidelines as Dental Plus

• Members are responsible to pay the difference between provider fee and the Dental Basic allowance.

• Participating providers receive 100% of the Dental Basic allowance

• In area non-participating provider – member is reimbursed 80% of Dental Basic allowance • Out of Area non-participating provider – member is reimbursed 100% of Dental Basic

allowance • No withhold • No deductible

• A $1,000 per member per year maximum applies to all services except orthodontia • A separate $1,000 per member lifetime maximum applies to orthodontic benefits

HMO 100 / 100 Plus

• Examination and prophylaxis covered 2 times per year • Specialist copay (which can be collected up front) • All other services are the responsibility of the patient • No withhold

• No deductible

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Federal Employee Program

• FEP has an established list of covered procedure codes and a specific fee schedule

• Participating provider can bill for the difference between the FEP allowed and the maximum allowable charge (MAC). The MAC is the Dental Plus allowance.

• Non-participating provider can bill up to charges • No withhold

Self Insured / ASO (Administrative Services Only)

Accounts: Bailee , Goodyear, Mark IV with Dental added to Medical

• Benefits determined by account • Pays Dental Plus fee schedule • No withhold

Dental Blue III, High & Low Options

• Dental Blue III, High, Low fee schedules • Same administrative guidelines as Dental Plus • Provider can balance bill members

• No withhold • No deductibles

Providers should always bill their usual and customary fees

Pre-Treatment Estimates

Pre-treatment estimates must be submitted for the following: • Crowns

• Inlays/Overlays and Veneers • Bridgework

• Full or partial dentures

• Periodontal surgery (including periodontal charting)

• Do not send x-rays with pre-treatment estimates or claims for actual services

Claims and Inquiries

BlueCross BlueShield of Western New York P.O. Box 80

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D

ENTAL

P

ROVIDER

S

ERVICE

Network Management Department

The BlueCross BlueShield Network Management Department representatives are available to assist you by providing in-office training on claim submission policies and procedures and answering any questions you may have about Dental benefits.

Provider Service Call Center

Our Provider Call Centers can assist you with member eligibility, claim inquiries, and member benefits. To expedite a response to your question, please have ready all information relevant to the claim.

Dental Provider Service Phone List

Network Management

To schedule on-site training with your Representative please call: (716) 887-2054 or (800) 666-4627

Department hours: 8:00 a.m. to 5:00 p.m.

Provider Call Centers

Community Blue: (716) 882-2616 or (800) 950-0052

Senior Blue: (877) 327-1395 – toll free

Traditional Blue: (716) 884-3461 or (800) 950-0051

Department hours: 8:30 a.m. to 5:00 p.m.

FEP Dental Program

(716) 884-5082 or (800) 234-6008

Department hours: 8:30 a.m. to 5:00 p.m. Member Services Phone List

Buffalo and Western New York

(716) 884-0774 or (800) 888-0757

Department hours: 8:30 a.m. to 5:00 p.m. M-F

Major and National Account Services

Subscriber claim, benefit and enrollment: (716) 885-4611 or (800) 888-0130

Department hours: 8:30 a.m. to 9:00 p.m. M-F 9:00 a.m. to 3:00 p.m. Saturday

Olean and Jamestown Satellite Offices

Olean: (716) 376-6000 or (800) 887-8130 Jamestown: (716) 484-1188 or (800) 944-2880

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WNYHealthenet is Western New York’s only HIPAA compliant health information network that offers physicians, providers, and office staff access to a patient’s health information using simple and fast, web-based transactions. For dental providers and their office staff member eligibility and claims status are available on-line.

WNYHealthenet is available to providers participating with BlueCross BlueShield of Western New York, Independent Health, or Univera. Signing up is easy – it’s a simple matter of submitting a few verification forms located at the website, which is

www.wnyhealthenet.com.

Supplies

The following stock items are available to assist participating BlueCross BlueShield Dental providers:

• BlueCross BlueShield Dental Provider Manual • Dental Claim Inquiry Forms

• Red Dental Claim forms for Paper Submissions

Utilization Management and Predetermination of Benefits

The Utilization Management and predetermination process is designed to ensure appropriate, cost effective use of subscriber benefits.

Predetermination

Services for payment and for predetermination should be submitted separately.

A treatment plan must be submitted for predetermination by the Participating dentist prior to performing any of the following dental services:

A. Crowns

B. Inlays/Onlays and Veneers C. Bridgework

D. Full or partial dentures

E. Periodontal surgery (include periodontal charting).

To submit a treatment plan for predetermination, please use the ADA dental claim form and: • Check the box marked "Dentist's Pre-Treatment Estimate" (located at the top of the

form).

• Do not fill in dates of service or sign the form.

• Mail the completed ADA dental claim form to BlueCross BlueShield at: BlueCross BlueShield of Western New York

P.O. Box 80

Buffalo, NY 14240-0080

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Upon completion of services, please fill in the dates of service, sign and date the form and mail it to BlueCross BlueShield in the claims envelope enclosed with the estimate.

Supporting Documentation

BlueCross BlueShield may request additional x-rays, reports, or other supporting materials when reviewing treatment plans for predetermination. If you receive a request for additional information, please indicate on the top right of each document the:

• Member name

• Member identification number • Provider name

• Practice address

All supporting documentation should be mailed to the address indicated on the request form: BlueCross BlueShield of Western New York

P.O. Box 80

Bill Your Usual and Customary Charge

Regardless of the allowance for a service, you should always bill your usual and

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D

ENTAL

P

RODUCTS

Dental Plus

Product Information

To meet the needs of subscriber groups; Dental Plus is available with or without subscriber deductibles and orthodontic benefits.

No Deductible:

• Preventive and Diagnostic - 100%

$1,000 Calendar Year Maximum Per Member • Sealants and space maintainers - 80%

$1,000 Calendar Year Maximum Per Member

May Be Subject to Deductible:

• Restorative, Periodontic, Endodontic and Oral Surgery - 80% $1,000 Calendar Year Maximum Per Member

• Prosthodontic - 50%

$1,000 Calendar Year Maximum Per Member • Orthodontic - 50%

$1,000 Lifetime Maximum Per Member

Deductibles

When applicable, the $50 individual/$150 family deductibles apply to all services except diagnostic and preventive.

Maximums

A $1,000 per member per calendar year maximum applies to all services except orthodontia. A separate $1,000 per member lifetime maximum applies to contracts with orthodontic benefits.

Exclusions

Dental Plus exclusions are described in detail in the contract and Section V, Procedure Codes, in this manual.

Dental Plus Risk and Compensation

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Dental Basic

Administrative Guidelines

Dental Basic uses the same administrative guidelines as Dental Plus with the following exception: Risk and Compensation.

Risk and Compensation

• The 10% withhold does not apply to Dental Basic.

• For Dental Basic, the subscriber is responsible to pay the difference between your fee and the amount in the Dental Basic schedule of allowances.

• When subscribers receive services from in-area Participating or OOA dentists, we pay the provider 100% of the Dental Basic schedule of allowances.

• When subscribers receive services from non-Participating dentists in Western New York, we pay the subscriber 80% of the schedule of allowances.

Dental Basic Benefits

Basic Contract

Oral Examinations & Cleanings

Periapical, bitewing and panographic x-rays Topical fluoride application

Prophylaxis

Palliative emergency treatment Fillings

Routine extractions

*Note: No additional periodontic dentists outside of the 2 routine cleanings/exams per year

Additional Dental Basic Benefits

Groups may purchase the following Dental Basic riders which provide additional benefits:

Rider A - Additional Basic Benefits

• Topical application of sealants • Space maintainers

• Inlays, onlays, and crowns, when not part of a bridge • Oral surgery and apicoectomy

• Bleaching of discolored teeth • Endodontics / Apicoectomy

Rider B - Prosthetic Services

• Dentures, full or partial • Bridges, fixed or removable • Denture relining

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Rider C - Periodontic Services

• Surgical periodontic examination • Gingival curettage

• Gingivectomy and gingivoplasty • Osseous surgery

• Mucogingivoplastic surgery

• Management of acute infection and oral lesions

• Periodontal scaling, root planing and occlusal adjustments

Rider D - Orthodontic Services

• Orthodontics: family contracts only; only children to age 19 • Cephalometric films

• Diagnostic casts & Orhtodontic Photographs

Rider 8 - Dependent Coverage to Age 23

Maximums

A $1,000 per member per calendar year maximum applies to all services except orthodontia. A separate $1,000 per member lifetime maximum applies to contracts with orthodontic benefits.

Deductibles

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Dental Blue

A group dental program that is no longer sold but still serviced in Buffalo Larger employer groups may carry Dental Blue as a StandAlone contract

Smaller groups can carry High of Low Option coverage to compliment their basic medical benefits.

Similar to Dental Basic but administered as three separate plans, III, High and Low with fee schedules unique to each plan

• No withhold/pooling

• Member pays the difference between the fee amount and the Dental Blue (III, High, Low) schedules of allowance

• All services pay at 100% of the applicable fee schedule regardless of the type of service rendered, the dentist’s location and whether the dentist participates with the BCBSWNY dental provider network.

Dental Blue Benefits Basic Contract

• Types of Services covered are identical to Dental Basic

Additional Dental Blue Benefits

Dental Blue Riders A,B,C,D equivalent to services covered under Dental Basic Riders A,B,C,D. • Does not include Topical Application of Sealants or Bleaching of Discolored Teeth.

Rider 8 – May have Dependent Coverage to Age 23 Maximums and Deductibles

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HMO 100 / 100 Plus

HMO 100 Plus offers a limited dental benefit to members which includes: • Examination and prophylaxis covered 2 times per year

• Specialist copay (which can be collected up front) • All other services are the responsibility of the patient • No withhold

• No deductible

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Self Insured / ASO (Administrative Services Only)

BlueCross BlueShield of Western New York administers dental benefits under our self-insurance agreements with:

Baillee Lumber (High Option Plan)

Baillee’s High Option Plan has added Dental benefits that are similar to the benefits and payment levels of Dental Plus with a $50/$150 Single/Family deductible. However, there is a $1,500 calendar year maximum per member rather than the $1,000 maximum under Dental Plus. All providers including non-par are paid directly by BCBSWNY for covered services.

Goodyear Tire & Rubber

Goodyear ASO benefits are similar to the full benefits version of Dental Basic and payment levels of Dental Basic.

Payment for services outside of WNY will be based on the Dental Basic allowance or the provider’s charge, whichever is less.

ASO plan members outside of WNY will pay the difference between the provider’s charge and the applicable dental fee schedule to their local Out-of-(WNY-)Area/non-par dental provider for all services.

Mark IV Dental Plan

Dental coverage including pharmacy benefits administered through Eckerd Health Services. All care over $200 requires a pre-determination. There is a $1,000 annual maximum and 15% coinsurance based on charges for services classified as Preventive Care, Restorative Care. There is a $1,000 annual maximum and 50% coinsurance based on charges for Dentures and Bridges. Orthodontics covered at 50% of charge with a lifetime maximum of $1,000.

Members can see any dentist but may be responsible for payment up to charge. All Reimbursement for covered services is made payable to the Subscriber.

Mark IV Medical Plan with Added Dental Benefits

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Binghamton Dental

A StandAlone Traditional Blue group Dental Program written for employees of the Upstate Medicare Division in Binghamton, New York which is serviced in Buffalo.

Arrangement follows rules for experience-rated business. Eligibility and terms of coverage is not unlike previously described Dental programs.

• No withhold/pooling

• Orthodontics is reimbursed at 50% of charge. All other services pay at 100% of the Dental Plus fee schedule regardless of provider network participation included non-par in area dentists.

• As there are no out-of-area participating dentists and members reside outside of WNY, members will pay the difference between the provider’s charge and the Dental Plus fee schedule to their local Out-of-(WNY-)Area provider for all services.

Benefits

Comparable to Dental Basic with all Riders (A) (B) (C) (D) & 8 except:

• All benefits are contained in the contract. There are no added benefit riders. • Diagnostic treatment including x-rays is covered as often as medically necessary

• Topical Application of Sealants is covered at 100% of the Dental Plus fee schedule to all providers.

• Dependent children are automatically covered to age 23.

Maximums and Deductibles

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FEP Dental

The FEP Dental PPO program utilizes the Dental Plus provider network. FEP Dental Provider eligibility is based on the following criteria:

• Current state license in good standing

• Certification by the provider that he/she is in compliance with all applicable federal and state laws and regulations

• Sufficient liability coverage, as determined by state requirements or norms FEP members are identified with an "R" suffix on their identification card.

FEP has an established list of covered procedure codes and a specific fee schedule. Participating dentists will receive direct payment, and will be permitted to bill for the

difference between the FEP allowance and the maximum allowable charge. Non-participating providers may bill to charge. This will be identified on the Explanation of Benefits payment voucher along with the variance amount which cannot be billed to the patient.

FEP Dental Provider Service:

(716) 884-5082

Department hours: 8:30 a.m. to 5:00 p.m. Mail claim inquiries to:

Blue Cross and Blue Shield of Western New York PO Box 80

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P

ROVIDER

R

EIMBURSEMENT AND

B

ILLING

G

UIDELINES

Explanation of Check/Summary and Payment Notice

Check/Summary Form

Provider payment checks are distributed weekly. Check/Summary Forms are included with the payment checks and list the total number of claims processed, total services processed and paid, adjustments, and withdrawn payments.

Payment Notice

Also included in the mailing of the payment check and summary form is your Payment

Notice(s). Payment notices give a detailed explanation of each claim by line of service.

Claims are listed in alphabetical order by patient's last name for easy referencing.

Adjustments reflecting additional or withdrawn payments are grouped separately at the end of the payment notice.

Payment Notice Field Descriptions:

Patient Name Claims are listed in alphabetical order by last name.

Subscriber ID Number Contains the subscriber's identification number from the claim submitted. Claim No. Contains the nine digit claim number.

Serv. Date Identifies the date(s) of service submitted for each procedure performed Proc. Code Indicates the 5 digit ADA procedure code representing the service performed.

Modifier is reserved for future use

Amount Billed Lists the dollar amount submitted by the dentist for each line of service Deductible Identifies the amount for which the subscriber is responsible before Dental

benefits are paid

Co-pay Amount by which the subscriber shares in the cost of covered services BCBSWNY Payment Represents the dollar amount paid for each line of service under the

subscriber's contract

Risk Pool 10% withhold applies to Dental Plus only Total Patient

Responsibility

Subscriber's total responsibility for deductibles, co-payments and non-covered services.

Variance The difference between the amount billed and the allowed amount. This _{amount may not be billed to the patient} EXPL Code If a service is a specific contract exclusion, or if payment is reduced or denied _{after dental review, an explanation code will appear. Definitions of these} Credit Applied

Adjustments

After all claims paid during the cycle are displayed, any adjustments made to a Participating dentist's account during the same cycle will be listed.

Adjustments are displayed by line and include both additional and withdrawn payments. Withdrawn payments are indicated with a minus sign. Adjustments contain a corresponding explanation code.

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Billing Tips

Timely Filing

Claims must be submitted within 90 days from the date of service for all services except the following: Endontic Therapy D3310 D3320 D3330 Anterior Biscuspid Molar Endodontic Retreatment D3346 D3347 D3348 Anterior Biscuspid Molar Apexification/Recalcification Procedures D3351 D3352 D3353 Initial visit Interim visit Final visit

Comprehensive Orthodontic Treatment D8070 D8080 D8090

Transitional dentition Adolescent dentition Adult dentition

Periodic Orthodontic Treatment Visit (as part of contract)

D8670

Claims for these procedures must be submitted within 90 days of completion of the above continuous service(s). Timely filing does not apply to National Accounts.

Coordination of Benefits

Coordination of Benefits (COB) is a method of coordinating payments for services when a subscriber has coverage through more than one insurance company. COB includes a subscriber's coverage through Workers' Compensation or No-Fault Auto insurance.

The primary carrier should be billed first. Any unpaid balances should then be submitted to the secondary carrier for consideration with an explanation of benefits from the primary carrier.

For services incurred by dependent children, the coverage of the spouse whose birthday (month & day only) falls earliest in the year will be primary. The coverage of the spouse whose birthday falls later in the year will be secondary.

If both parents have the same birthday, the benefits of the Plan or carrier which covered the parent longer will be determined before the benefits of the Plan or carrier which covered the other parent for the shorter period of time.

If another Plan or carrier does not abide to this rule then you revert to gender ruling.

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determined as follows:

1. First, the plan or carrier of the parent with custody of the child.

2. Then the plan or carrier of the spouse of the parent with custody of the child. 3. Finally, the plan or carrier of the parent not having custody of the child.

4. If the terms of a court decree state that one of the parents is responsible for the health care expenses of the child, the benefits of that Plan or carrier are determined first.

Appeal Process

If a covered service is denied and you disagree with the decision, contact our Special Services Department at 885-4611 or outside the Buffalo calling area, 1-800-888-0130. Special Services will refer your inquiry to the Utilization Management Department for review.

Services Started Prior to Coverage Date

We will not provide benefits for services which were started prior to the date the subscriber became covered under the Blue Cross and Blue Shield contract. We use the following guidelines to determine the date on which a service shall be deemed to have started: A. For full dentures or partial dentures: On the date the final impression is taken. B. For fixed bridges, crowns, inlays, onlays: On the date the teeth are first prepared. C. For root canal therapy: On the latter of the date the pulp chamber is opened or the date

the canals are explored to the apex.

D. For periodontal surgery: On the date the surgery is actually performed. E. For all other services: On the date the service is performed.

Denial: Invalid Tooth Number for Procedure

If you receive a denial due to “invalid tooth number for procedure” (eg. D1351, D2331, D2332, D2335,) please verify that the tooth number corresponds with the CDT code being billed. Valid tooth numbers for the anterior procedure codes are 6-11 and 22-27. All other tooth numbers should be billed with posterior codes.

To request and adjustment, please submit a written inquiry with a copy of your voucher and the corrected procedure code to the claims and inquiry address on page

Infection Control Allowance

Various factors are used when establishing allowances, including overhead costs. Infection control is an integral part of doing business and is therefore considered an overhead cost. This charge cannot be billed to our members.

Provider Claim Inquiry

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requests for all BlueCross BlueShield lines of business. For inquiries pertaining to dental contracts, providers should check the dental box in the "Inquiry Pertains to" field at the top of the form.

Providers should complete the top part of this form and submit it to BlueCross BlueShield with all required documentation. We will return the form to you with a response recorded on the lower portion.

To ensure we understand the nature of your request, please be sure to include the following information with your inquiry:

• The proper documentation (i.e. office records, operative reports, etc.)

• When requesting a claim adjustment to change a procedure code or allowance, please submit documentation substantiating the change.

Mail claim inquiries to:

BlueCross BlueShield of Western New York 1901 Main Street

PO Box 80

Provider Claim Inquiry Form

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Dental Question and Answer

Q: Do any of the contacts have a missing tooth clause, and if so, what is the time limit? A: Our dental products have a “pre-existing condition” clause. It states “We will [Health Plan]

not provide benefits for a denture or fixed bridge involving replacement of missing teeth before the individual was covered under this contract for a period of 3 years unless ir replaced a tooth that is extracted while covered under this contract.”

Q: How often will the Health Plan pay for replacements of crowns, bridges, partials, and dentures?

A: Once every five years.

Q: Does the Health Plan cover sealants?

A: One time per tooth every 36 months on first and second molars up to age 16. Q: What code should be billed for a difficult prophylaxis?

A: D1110, if there is no bone loss.

Q: What code should be billed for treating gingivitis? A: D1110, if there is no bone loss.

Q: What distinguishes a sealant from a preventative resin restoration?

A: If the caries is limited to the enamel, it is still considered a sealant. If the decay penetrates

the dentin, then this is considered a restorative procedure.

Q: What code do I use to report sealant material?

A: If sealant material is placed, report the sealant code D1351.

Q: What code do I use to report root canal therapy on a molar with 4 roots? A: Submit the endodontic therapy code for molars D3330.

Q: What code should I submit for a flipper? A: D5280 maxillary, D5281 mandibular.

Q: What should be billed to report re-cementing a single crown or fixed partial denture? A: Code D2920 reports re-cementing a single crown. Code D6930 reports re-cementing a fixed

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1901 Main Street PO Box 80

Buffalo, New York 14240-0080

PROVIDERCLAIMINQUIRY TO_(PLEASEBECOMPLETED_TYPE_OR_PRINTBYPROVIDER_FIRMLY) NOTE:CORRECTEDACOPYBILLINGOFORIGINALORVOUCHERCLAIM,

MUSTBEATTACHEDTOTHISFORM.

PROVIDER NAME, ADDRESS, ZIP CODE INQUIRYPERTAINSTO: TRADITIONALBLUE COMMUNITYBLUE DENTAL VISION GM OTHER

INQUIRYREASON: NOPAYMENTRECEIVED UNABLETOIDENTIFY PAYMENT UNDERPAYMENT OVERPAYMENT OTHER

FORCOORDINATIONOFBENEFITS,LISTINSUREDNAME,ID#,CARRIERNAME, ADDRESS:

BCBS PROVIDER # RELATIONSHIP TO SUBSCRIBER: SELF SPOUSE CHILD INSURED’S NAME (First name, middle initial, last name)

PATIENT’S NAME (First name, middle initial, last name)

PATIENTACCOUNT/MEDICALRECORD

DATE(S) OF SERVICE IDENTIFICATIONNO. GROUPNO. PLANCODE NUMBER,ORCLAIMNUMBER

ADDITIONAL INFORMATION:

DATE SIGNATURETYPE NAME HERE DEPARTMENT PHONENUMBER/EXTENSION

B L U E C R O S S B L U E S H I E L D P L A N R E S P O N S E

CLAIMPROCESSED CLAIM_PAID_CORRECTLYREVIEWED– _SUBSCRIBERCHARGESAPPLIED_DEDUCTIBLETO PAID_WILLIN_BEERROR_ADJUSTED–CLAIM

CLAIMWILLBE REPROCESSED

NOFURTHER

BENEFITSAVAILABLE PAYMENTOF $ MADEON OTHER

CLAIMREMAINSDENIED PATIENT_DATE_OFNOT_SERVICECOVEREDON CONTRACT_PERIOD_NOTWAITING_MET SERVICE_{SUBSCRIBER’S}NOTA_CONTRACTBENEFITIN CONTRACTCANCELLED NORESPONSEFROM

MEDICALINFORMATIONREVIEWED- NO

CHANGEINDECISION OTHER

COMMENTS:

DATE SIGNATURETYPE NAME HERE DEPARTMENT PHONENUMBER/EXTENSION

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