Printable Maryland State Claim Template

The Maryland State Claim Form is a document specifically designed for members of the State Employees Health Plan to submit claims for health care services. This form facilitates the process of filing claims for services received from non-participating providers, ensuring that members can receive the benefits they are entitled to under their health plan. Completing the form accurately is crucial for prompt processing of claims.

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The Maryland State Claim form is a vital document for members of the State Employees Health Plan, enabling them to file claims for medical services received. This form is specifically designed for claims related to PPO, POS, and EPO services, particularly when non-participating providers are involved. Key sections of the form require the subscriber's and patient's legal names, membership numbers, and details about the treatment received. Important questions address the nature of the treatment, such as whether it resulted from an injury or automobile accident, and whether the patient has other health insurance coverage, including Medicare. To ensure successful processing of claims, it is crucial to provide itemized bills that include essential information like the provider's details, descriptions of services, and the amount charged. The form also includes a certification section, where the subscriber affirms the accuracy of the information provided. Completing this form accurately and submitting it along with the necessary documentation is essential for receiving timely health benefits.

Maryland State Claim Preview

CUT5803-1S (10/14)

Do not write in this space

STATE OF MARYLAND EMPLOYEES HEALTH CLAIM FORM

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

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.

Date

Was the treatment a result of an injury?

q Yes q No

Was the treatment a result of an automobile accident?

q Yes q No

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)?

q Yes

q No

Month

Day

Year

CLAIM NUMBER

b. Medicare Part B (Physician’s Coverage)? q Yes

q No

Month

Day

Year

In addition to coverage under this program, is patient covered under any other insurance providing health care benefits or services?

q Yes q No

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

Year

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.

SIGNATURE OF SUBSCRIBER

DATE

HAVE YOU ATTACHED YOUR ITEMIZED BILLS?

Administrative Use Only

Do not write in this space

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

STATE OF MARYLAND EMPLOYEES HEALTH CLAIM FORM

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

Click for Maryland State Claim File

Form Attributes

Fact Name	Description
Form Purpose	This form is specifically for members of the State Employees Health Plan to file claims for PPO, POS, and EPO services.
Submission Requirements	All claims must include itemized bills, a completed claim form, and any necessary additional documentation such as Explanation of Benefits from other insurance carriers.
Governing Law	The use of this form is governed by the Maryland State Employees Health Plan regulations and guidelines.
Important Notes	Claims must be submitted with original bills and receipts, and all questions on the form must be answered to avoid delays in processing.

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