Note: Canceled checks, cash register receipts, balance due statements, or bills you prepare yourself are not acceptable substitutes for itemized bills. Dates that services or supplies were furnished.Name and address of person or company providing the service or supply.Patient’s name, date of birth, address, phone number, and relationship to enrollee.Bills and receipts should be itemized and show: For long or continuing inpatient stays, or other long-term care, you should submit claims at least every 30 days. Use a separate claim form for each family member.
When you must file a claim – such as when another group health plan is primary – submit it on the CMS-1500 or a claim form that includes the information shown below. Your facility will file on the UB-04 form. Your provider must file on the CMS-1500, Health Insurance Claim Form. Just present your ID card when you receive services. To obtain claim forms or other claims filing advice, or answers to your questions about our benefits, contact us at the customer service phone number on the back of your ID card, or at our website at In most cases, physicians and facilities file claims for you. See Section 3 for information on pre-service claims procedures (services, drugs, or supplies requiring precertification or prior approval), including urgent care claims procedures. This Section primarily deals with post-service claims (claims for services, drugs, or supplies you have already received).
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