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Fill in a Valid Massachusetts Claim Form

The Massachusetts Claim Form is a document used by subscribers to request reimbursement for medical services when their healthcare provider does not submit a claim directly to the local Blue Cross Blue Shield plan. This form is essential for ensuring that patients receive the financial support they are entitled to after receiving care. Understanding how to properly complete and submit this form can make a significant difference in the claims process.

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Fill in a Valid Massachusetts Claim Form

Article Structure

The Massachusetts Claim Form is a crucial document for members seeking reimbursement for medical services when their healthcare provider does not submit a claim directly to the local Blue Cross Blue Shield (BCBS) plan. To initiate the claims process, individuals must complete a separate form for each patient, ensuring they attach an original itemized bill from the provider, which must include specific required information. Essential details such as the subscriber's identification number, personal information, and the patient's details—including their relationship to the subscriber—must be accurately filled out. The form also requires information about any other insurance coverage the patient may have, along with relevant accident details if applicable. After signing and dating the form, claimants should mail it, along with all attachments, to the designated BCBSMA address. It is important to retain copies of all submitted documents, as originals will not be returned. Processing claims can take up to 30 days, so timely submission is advisable for quicker reimbursement.

Massachusetts Claim Example

SUBSCRIBER CLAIM FORM

Instructions for Submitting Claims

1.Submit a claim only when you are billed for services from a provider that does not directly submit a claim to the local Blue Cross Blue Shield plan.

2.Submit a separate form for each patient.

3.Attach an original itemized bill from your provider (required information & example on the back)

4.Keep a copy of all bills and claim forms submitted (originals will not be returned)

5.Be sure to sign and date the completed form.

6.Mail claim form and all attachments to BCBSMA, P.O. Box 986030, Boston, MA 02298

Subscriber Information

Identiﬁcation Number (including alpha preﬁx)

Last Name

First Name

Middle Initial

Address-Number & Street

City

State

Zip Code

Date of Birth (MM/DD/YY)

Employer’s Name

Patient Information

Patient Last Name

First Name

Middle Initial

Date of Birth (MM/DD/YY)

Gender:

qMale

qFemale

Patient is:

q Subscriber (contract holder) q Student (age 19 or older) q Other (specify)

q Spouse (to contract holder)q Child (age 18 or younger) q Handicapped Dependent (age 19 or older)

Does the patient have other insurance: q Yes q No

		Effective Date:
Medicare Part A (Hospital)		q Yes q No ____/____/_____
Medicare Part B (Medical)		q Yes q No ____/____/_____
Medicare Part D (Pharmacy)		q Yes q No ____/____/_____
Other Blue Cross
Blue Shield Membership?		q Yes q No ____/____/_____
Other Insurance Plan?		q Yes q No ____/____/_____
Identiﬁcation Number:

Name and address of other insurance:

Was treatment for:

Accident at work? q Yes q No

Date of accident ____/____/_____

Auto accident? q Yes q No

Date of accident ____/____/_____

If yes, name of auto insurance:

Policy Number:

Other accident? q Yes q No

Date of accident ____/____/_____

Subscriber Signature:

Date:

Please allow up to 30 days for your claim to process.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Example of a Complete Itemized Bill

Smith Speech Center

123 Main St.

Boston, MA 12345

To: Joe Smith

Patient Name: Joan Smith

15 Elm St.

Referring Doctor: Dr. John Jones

Anytown, MA 12345

Provider

Jane Johnson,

SLP, CCC

Tax ID/NPI: 99-9999999

Speech-Language Pathologist

Credentials

License # Y777777

Procedure Code(s)

Units

Procedure Description

Date of Service

Amount

92507

Speech–Language Therapy

10/5/2008

$72.50

Itemized

Charges

92507

Speech–Language Therapy

11/3/2008

$145.00

Diagnosis Codes: 784.50, 315.31

Total: $290.00

Payments: $290.00

Balance Due: $0.00

Please note that your bill does not need to look exactly like the example above, but MUST contain the following required information:

1.A letterhead from the provider that MUST include all of the following:

–Provider name

–Provider address

–Provider Tax ID/NPI

–Provider credentials, i.e., the initials associated with the educational degrees the provider has earned. Examples include: MD, LICSW, DC, PT, OT, ST

2.Patient’s name

3.Date(s) of service

4.Itemized charges for each date of service and type of service received

5.Procedure codes (HCPCS/Revenue codes) for all services received

6.Diagnosis code(s) for services received

7.Number of Units-this is the number of times a service was performed on a particular date of service. This is required for occupational, physical & speech therapies, anesthesia and chiropractic services.

8.Attach any related claim summaries or Explanation of Medicare Beneﬁt Forms you may have received for these services, including those received from other insurance companies.

9.When submitting a claim for PRESCRIPTION DRUGS, you must submit an itemized receipt from your pharmacy that includes:

–National Drug Code (NDC)

–Name of drug

–Date dispensed

–Quantity dispensed

–Name of prescribing physician

To view processed claims, visit our website http://www.bluecrossma.com/wps/portal/members/. If you have not already registered for Member Central, click Create an Account and follow the directions.

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(10/10) PDF

Download Massachusetts Claim PDF Form

Form Specs

Fact Name	Details
Claim Submission Requirement	A claim should be submitted only when billed for services from a provider who does not directly submit a claim to the local Blue Cross Blue Shield plan.
Separate Forms for Each Patient	Each patient requires a separate claim form, ensuring that individual claims are processed correctly.
Original Itemized Bill	An original itemized bill from the provider must be attached to the claim form, which includes specific required information.
Retention of Copies	It is essential to keep copies of all bills and claim forms submitted, as originals will not be returned.
Signature Requirement	The completed claim form must be signed and dated by the subscriber to validate the submission.
Mailing Address	Claims should be mailed to BCBSMA at P.O. Box 986030, Boston, MA 02298.
Processing Time	Subscribers should allow up to 30 days for their claim to be processed after submission.
Governing Law	This claim form is governed by Massachusetts insurance regulations and the policies of Blue Cross Blue Shield of Massachusetts.

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