Online claim example 2: If you made two separate purchases and each purchase covered three members, you would need to submit six separate claim forms. Each test within a package is counted individually. Visit the CDC website for the most up-to-date testing guidance. You will be reimbursed for over-the-counter COVID-19 diagnostic tests purchased on or after January 15, 2022. You may need to visit a doctor or hospital while traveling in another state. A nurse case manager with Blue Cross & Blue Shield of Rhode Island found that listening, without judgment, to one patients concerns made all the difference. 1996-document.write(new Date().getFullYear()); Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. You can be reimbursed (paid back) for both: Medi-Cal members: Do NOT use this page for test reimbursement. You can use these claim forms to ask us for reimbursement. Once we process your claim, the contract holder will receive a reimbursement check by mail. If you have any questions about your reimbursement claim submission, call . You'll be reimbursed up to $12 per individual test. In addition, some sites may require you to agree to their terms of use and privacy policy. To file a claim for those out-of-network services, youll need to use the claim form from the state where you were treated. this.set=function(a,c){var b="",b=new Date;b.setTime(b.getTime()+6048E5);b="; expires="+b.toGMTString();document.cookie=a+"="+c+b+"; path=/; "}; With a BCBSTX health plan, you have access to care for COVID-19 related health issues. Tests that can be purchased at a retail location or online but are then sent to a lab for processing are not covered unless accompanied by a doctor's order (except for individuals covered by plans based in the District of Columbia). BCBS recognizes doctors and hospitals for their expertise and exceptional quality in delivering care. To view this file, you may need to install a PDF reader program. bxx,|
To qualify: . Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. All information below is required. Message and data rates may apply. Please review the terms of use and privacy policies of the new site you will be visiting. If you paid for a COVID-19 test and think you might qualify for reimbursement, read the COVID-19 Testing Member Reimbursement Form (PDF) to find out more. Reimbursement will be in the form of a paper check in U.S. currency and mailed to the address provided on your Retail Prescription Drug Overseas Claim Form. To print and mail your claim, download theclaim form (PDF). Blue Shield of California is an independent member of the Blue Shield Association A53064-FF . Diagnostic tests are performed if you are experiencing COVID-19 symptoms or have been recently exposed. However, you must include all required information requested in the form. More than 140 million Americans have received a dose of the COVID-19 vaccine. cRequired for employment purposes. *CVS Caremark is an independent company that has been contracted to administer your pharmacy benefits for Blue Cross Blue Shield of Massachusetts. Medicare Advantage members: Use the claims form for OTC at-home tests with a healthcare provider order. The California Department of Health Care Service (DHCS) will reimburse the cost of your at-home tests purchased from March 11, 2021, to January 31, 2022. OTC tests, also known as self-tests, detect if you are currently infected with COVID-19. If you have employer coverage, or an individual or family plan, you can get FDA-authorized, over-the-counter COVID-19 tests for diagnosing COVID-19 through your BCBSTX/Prime Therapeutics. Additional details about at-home COVID-19 testing can be found on the Blue Cross Blue Shield website. Some testing locations may not be in your health plans network, particularly if they arent part of a medical group or facility. The protection of your privacy will be governed by the privacy policy of that site. Leading the way in health insurance since 1929. Buying tests to store them for a potential need isn't good for the community or public health.
Mail-in claims The Blue Cross Blue Shield Association is an association of 35 independent, locally operated Blue Cross and/or Blue Shield companies. c I had COVID-19 symptoms. People may also access free or affordably priced testing in the community. One option is Adobe Reader which has a built-in screen reader. All rights reserved. You will be reimbursed via check, mailed to the address we have on file within 30 days of Blue Cross Blue Shield of Arizona (BCBSAZ) receiving your reimbursement information. Most PDF readers are a free download. This policy will remain in effect for the duration of the Federal Public Health Emergency. endstream
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Quality Care Thats Right for YouWhether you need a routine check-up or a specialty procedure, you want the best care you can find. If any information is missing from the invoice, contact the provider. s&jPDed
Online claim example 1: Lets say you made a one-time purchase of up to 24 tests for three members. try{(new g(100,"r","QSI_S_ZN_eQKLROMaB9E1yfz","https://zneqklromab9e1yfz-carefirst.siteintercept.qualtrics.com/SIE/?Q_ZID=ZN_eQKLROMaB9E1yfz&utm_source=Qualtrics")).start()}catch(i){}})(); Keep your purchase receipt (s) to submit for reimbursement. To access your member services, please visit your BCBS company. CareFirst of Maryland, Inc. CareFirst Community Partners, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Substance Use Treatment & ResourcesLearn more about substance use disorders and find a treatment provider that meets your needs. As part of our mission to improve and protect the healthcare system, particularly under the threat of the Coronavirus/COVID-19, the Blue Cross Blue Shield Association is focused on protecting members from fraudsters who seek to take advantage of the fear and confusion many feel surrounding the coronavirus/COVID-19 during these uncertain times. Waiving all prior authorization requirements for COVID-19 testing and related covered services. 2023 Blue Cross Blue Shield Association. COVID-19 Coverage for Members Your health is always our priority. Over-the-counter COVID-19 tests will not be covered by your medical or pharmacy benefits after the end of the public health emergency. To pay no out-of-pocket costs, order your tests online through cvs.com or the CVS Pharmacy mobile app for store pickup1. The site may also contain non-Medicare related information. Check out the changes and updates to our plan in 2023. Over-the-counter COVID-19 tests will not be covered by your medical or pharmacy benefits after the end of the public health emergency. Paper Claim Form. For help with these documents, please call 1-800-975-6314. This page may have documents that cant be read by screen reader software. If your employer has asked you to submit receipts to your pharmacy benefit plan, please dont submit them here. Call your doctor. a|VOXHXT:B4
California Physicians Service DBA Blue Shield of California is an independent member of the Blue Shield Association. endstream
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Once you reach the limit of eight tests per member per calendar month, we will not reimburse claims for additional tests. If you have health coverage through a large employer, we recommend you contact your Benefits or HR Administrator to determine if your over-the-counter COVID-19 testing claim should be submitted to CareFirst as a medical claim or to your employers Pharmacy Benefit Manager as a pharmacy claim. What Impacts the Cost of Health Insurance? Wu3B=
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See our FAQfor detailed instructions. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Search for Doctors, Hospitals and Dentists Blue Cross Blue Shield members can search for doctors, hospitals and dentists: In the United States, Puerto Rico and U.S. Virgin Islands. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. If you purchase at-home tests without an order from your healthcare provider, you can be reimbursed for up to eight individual tests per member, per month. ro?gu?"t6Vr
K?K@n}r`TyEycB". Medicare Advantage COVID-19 Testing Member Reimbursement Form Mail your completed claim form with a copy of your receipt(s) to: Blue Shield of California California Physicians Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Substance Use Treatment & ResourcesLearn more about substance use disorders and find a treatment provider that meets your needs. For example, a physician, a nurse practitioner, or a physician assistant. Member Discounts Take advantage of member-only discounts on health-related products and services. All Rights Reserved. You can also include multiple receipts with one form. Coverage varies by plan type. With each claim form, you should include the same receipt. According to the Centers for Disease Control (CDC) recommendations, if your over-the-counter test has a positive result, you should follow the latest CDC guidance for isolation, wear a well-fitted mask if you have contact with others and call your healthcare provider. To access your member services, please visit your BCBS company. To view this file, you may need to install a PDF reader program. If you do not have an itemized receipt, you must send us the barcode (UPC code) from your test (s) packaging. To live free of worry, free of fear, because you have the strength of Blue Cross Blue Shield companies behind you. Read Full Story Audience Communities Get access to your member portal. 510 0 obj
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Making healthcare affordable. IMPORTANT CORONAVIRUS/COVID-19 ANTI-FRAUD MESSAGE TO CONSUMERS. Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. Group Hospitalization and Medical Services, Inc., and First Care, Inc. CareFirst BlueCross BlueShield Medicare Advantage is the shared business name of CareFirst Advantage, Inc., CareFirst Advantage PPO, Inc. and CareFirst Advantage DSNP, Inc. CareFirst BlueCross BlueShield Community Health Plan Maryland is the business name of CareFirst Community Partners, Inc. CareFirst BlueCross BlueShield Community Health Plan District of Columbia is the business name of Trusted Health Plan (District of Columbia), Inc. To be eligible for reimbursement, the purchased over-the-counter at-home COVID-19 tests: must be purchased on or after January 15, 2022 must be for personal diagnostic use used to identify the potential COVID-19 infection not be used for employment purposes not used for surveillance testing Mail-in claim forms allow you to submit a claim for multiple members with one form. endstream
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If you have Medicare, you can go to www.empireblue.com/medicare for information about your plan. Check the state-by-state list of Blue Cross Blue Shield companies to get started. 1To download the BCBSTX app, text BCBSTXAPP to 33633 or search for BCBSTX in the Apple App Store or Google Play. Thats a big step toward stopping the spread of the virus. You do not need health insurance to receive your free tests. Discover all the ways members can earn wellness incentives and rewards for taking an active role in their health. *Thisprocess applies to members with individual, employer-sponsored or student health plan coverage, as well as Federal Employee Program (FEP) and Federal Employee Health Benefits Program (FEHBP) plan members. If you are covered by a group or individual and family health plan, you can get reimbursed for your purchase of FDA-authorized, at-home testing kits at $12 per test, or $24 for a box that includes two tests, for up to 8 tests per person every 30 days. O=>WNW%
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this.go=function(){if(this.check()){var a=document.createElement("script");a.type="text/javascript";a.src=g;document.body&&document.body.appendChild(a)}}; The list will be updated as new FDA-authorized tests become available. For additional COVID-19 information, visit the Blue Cross Blue Shield Coronavirus Resource Center. Your questions answered: the COVID-19 vaccine for pre-teens and teens, I listened: A nurse case manager on addressing vaccine hesitancy, Blue Cross and Blue Shield of Alabama COVID Vaccination Efforts, BCBSAL partners with state, community on COVID-19 relief, Blue Cross and Blue Shield of Alabama Prepared to Meet the Needs of Customers In the Event of Sustained Spread of COVID-19, Blue Cross and Blue Shield of Alabama: Coronavirus (COVID-19) Update Center, Blue Cross and Blue Shield of Alabama Expands Telehealth Coverage as Customers Health and Well-Being Remains Top Priority, Premera Blue Cross and Blue Shield of Alaska, Premera Blue Cross and Blue Shield of Alaska COVID Vaccination Efforts, Blue Cross Blue Shield of Arizona COVID Vaccination Efforts, Blue Cross Blue Shield of Arizona Employees Volunteer to Assist with Covid-19 Patient Treatment, Blue Cross Blue Shield of Arizona Expands Support For Coronavirus Services And Care, Waives Telehealth Cost Share For Members, Arkansas Blue Cross and Blue Shield COVID Vaccination Efforts, BCBS Arkansas tackles food security in wake of COVID-19, BCBS of Arkansas Information for Medicare Advantage Members, COVID-19 Update for Members covered by Arkansas Blue Cross/Health Advantage (Fully Insured), Arkansas Blue Cross providing online sales and service, temporarily closing retail stores, Anthem Blue Cross COVID Vaccination Efforts, Anthem Simplifies Care Provider Protocols to Help Deliver Safe, Effective and Timely COVID-19 Care, Anthems affiliated health plans waive member costs for COVID-19 testing, while supporting telehealth and 90-day maintenance medication supply, Anthem Issues Updates Regarding COVID-19 Testing and Care to Support Affiliated Health Plan Members, Blue Shield of California COVID Vaccination Efforts, Blue Shield of California expanding access to care during pandemic, Blue Shield of California Gives $100,000 to Nonprofit MedShare for COVID-19 Response in Underserved Communities, Blue Shield of California Gives $500,000 to Oakland COVID-19 Relief Fund, Blue Shield of California Information for Members, Blue Shield of California Waiving Cost-Sharing and Prior Approval for Coronavirus Testing, Blue Shield of Californias BlueSky Launches 'New State of Mind' Digital Campaign to Support Youth Mental Health and Resilience, Anthem Blue Cross and Blue Shield Colorado, Anthem Blue Cross and Blue Shield Colorado COVID Vaccination Efforts, Anthem Blue Cross and Blue Shield Connecticut, Anthem Blue Cross and Blue Shield Connecticut COVID Vaccination Efforts, Highmark Blue Cross Blue Shield Delaware COVID Vaccination Efforts, Highmark Expands Telehealth Opioid Treatment Program to Pennsylvania, Delaware During Covid-19 Crisis, Carefirst Bluecross Blueshield Announces Volunteer Program for Coronavirus Response and Relief, CareFirst BlueCross BlueShield Announces Substantial Actions to Further Increase Access to Care During Coronavirus Pandemic, BCBS Florida partners with community organizations during pandemic, Coronavirus Update: Florida Blue Increasing Access to Health Care Services for Members to Aid in Treatment, Florida Blue Increasing Access to Health Care Services to Aid in Coronavirus Treatment, Free 24/7 Bilingual Helpline Open to Provide Emotional Support during COVID-19 Health Crisis, Blue Cross Blue Shield of Georgia COVID Vaccination Efforts, Blue Cross and Blue Shield of Hawaii COVID Vaccination Efforts, BCBS Hawaii and its foundation distribute aid in wake of COVID-19, HMSA announces steps to help members prepare for COVID-19, Wellmark Blue Cross and Blue Shield COVID Vaccination Efforts, Wellmark announces important health plan updates regarding coronavirus, Blue Cross of Idaho COVID Vaccination Efforts, BC Idaho and its foundation respond to community needs amidst COVID-19, More Steps from Blue Cross of Idaho to Support Members During the Coronavirus Pandemic, Blue Cross of Idaho Foundation for Health contributes to COVID-19 response fund, Regence BlueCross BlueShield COVID Vaccination Efforts, Regence BlueShield of Idaho to cover cost of coronavirus (COVID-19) testing for members, Blue Cross and Blue Shield of Illinois COVID Vaccination Efforts, HCSC supports community needs during COVID-19, Health Care Service Corporation Information for Members, Blue Cross and Blue Shield of Illinois Responds to COVID-19 by Further Expanding Telehealth and Waiving Member Cost-Share, Anthem Blue Cross and Blue Shield Indiana, Anthem Blue Cross and Blue Shield Indiana COVID Vaccination Efforts, Anthem Blue Cross and Blue Shield invests $50M+ in COVID-19 response efforts, Blue Cross and Blue Shield of Kansas COVID Vaccination Efforts, BCBS Kansas supporting child welfare and families during COVID-19, BCBS of Kansas: Coronavirus: How we're responding to COVID-19, Anthem Blue Cross and Blue Shield Kentucky, Anthem Blue Cross and Blue Shield Kentucky COVID Vaccination Efforts, Blue Cross and Blue Shield of Louisiana COVID Vaccination Efforts, Blue Cross and Blue Shield of Louisiana Statement on COVID-19, Blue Cross Platform Powers COVID-19 Louisiana Outbreak Tracker in Collaboration with State Health Department, Video: How big data in healthcare is predicting the future and improving lives, Blue Cross and Blue Shield of Massachusetts, Blue Cross and Blue Shield of Massachusetts COVID Vaccination Efforts, BCBS Massachusetts supports public health, nonprofits during COVID crisis, BCBS of Massachusetts Information for Members, BCBS of Massachusetts Statement on Testing and Care Related to COVID-19, Blue Cross Blue Shield of Massachusetts Expands Coverage and Access for Members During the Coronavirus Pandemic, CareFirst BlueCross BlueShield COVID Vaccination Efforts, CareFirst responds to COVID-19's dual public health and economic crisis, Anthem Blue Cross and Blue Shield Maine COVID Vaccination Efforts, Blue Cross Blue Shield of Michigan COVID Vaccination Efforts, BCBS Michigan investing in access to support communities during COVID-19, More Than 30 Blue Cross Blue Shield of Michigan Employees Volunteer for Front-Line Work to Assist in Treating Covid-19 Patients, Blue Cross Blue Shield of Michigan Will Waive Member Copays and Deductibles for COVID-19 Tests, Among Series of Proactive Steps on Coronavirus, Blue Cross Blue Shield of Michigan Information for Members, Blue Cross Blue Shield of Michigan Statement and Waiving of Copays/Deductibles, Blue Cross and Blue Shield of Minnesota COVID Vaccination Efforts, Blue Cross and Blue Shield of Minnesota fights food insecurity and protects healthcare workers, Blue Cross joins Allina to launch skilled volunteer effort to create masks for hospitals and clinics, Blue Cross and Blue Shield of Minnesota announces $750,000 commitment to Second Harvest Heartland, Blue Cross and Blue Shield of Minnesota Information for Members, Anthem Blue Cross and Blue Shield Missouri, Blue Cross and Blue Shield of Kansas City, Anthem Blue Cross and Blue Shield Missouri COVID Vaccination Efforts, Blue KC driving better health by investing in community engagement, Blue Cross and Blue Shield of Kansas City Announces It Will Cover COVID-19 Testing and 24/7 Access to Virtual Care, BCBS of Kansas City Information for Members, Blue Cross And Blue Shield Of Kansas City Announces It Will Cover COVID-19 Testing And 24/7 Access To Virtual Care, Blue Cross and Blue Shield of Mississippi, Blue Cross & Blue Shield of Mississippi COVID Vaccination Efforts, BCBS Mississippi alleviates food insecurity during COVID-19 crisis, BCBS of Mississippi Information for Members, Blue Cross and Blue Shield of Montana COVID Vaccination Efforts, COVID-19 Coverage for BCBS of Montana Members, Blue Cross and Blue Shield of North Carolina, Blue Cross and Blue Shield of North Carolina COVID Vaccination Efforts, BCBS North Carolina supporting community nonprofits during pandemic, Thrive NC Postponed until 2021; Blue Cross NC Commitment to Food Security Remains, BCBS of North Carolina Information for Members, Blue Cross North Carolina to Cover Member Cost of Coronavirus Test, Blue Cross Blue Shield of North Dakota COVID Vaccination Efforts, BCBS of North Dakota Information for Members, How BCBS of North Dakota is responding to coronavirus to help protect the health of all North Dakotans, Blue Cross and Blue Shield of Nebraska COVID Vaccination Efforts, How Blue Cross and Blue Shield of Nebraska is responding to the coronavirusand what you need to know, Anthem Blue Cross and Blue Shield New Hampshire, Anthem Blue Cross and Blue Shield New Hampshire COVID Vaccination Efforts, Horizon Blue Cross and Blue Shield of New Jersey, Horizon Blue Cross and Blue Shield of New Jersey COVID Vaccination Efforts, 72 Doctors, Nurses, Pharmacists and Health Clinicians from Horizon Answer Governor Murphys Healthcare Professionals Call to Serve, Horizon Commits $2.36 Million for Masks, Face Shields, Food, and Social Services to Protect Our Communities and Our Health Professionals, Horizon Announces Initial Steps to Support Members Through COVID-19 Outbreak, Blue Cross and Blue Shield of New Mexico COVID Vaccination Efforts, Anthem Blue Cross and Blue Shield Nevada COVID Vaccination Efforts, Empire Blue Cross Blue Shield COVID Vaccination Efforts, BCBS Western New York supporting nonprofits during COVID-19, BCBS of Western New York Information for Members, BCBS of Western New York COVID-19 (Coronavirus) Message to Members, Excellus BlueCross BlueShield COVID Vaccination Efforts, Excellus BCBS responds to COVID-19 with $162 million for community, Excellus BCBS Updates on COVID-19 (Coronavirus), Anthem Blue Cross and Blue Shield Ohio COVID Vaccination Efforts, Blue Cross and Blue Shield of Oklahoma COVID Vaccination Efforts, Regence BlueCross BlueShield of Oregon taking action to support members through coronavirus (COVID-19) outbreak, Capital Blue Cross COVID Vaccination Efforts, Capital Blue Cross Information for Members, Capital BlueCross Temporarily Modifies Coverage to Help Members Deal with Spread of COVID-19, Highmark Blue Cross Blue Shield COVID Vaccination Efforts, Allegheny Health Network, Highmark to announce drive-up testing sites Wednesday, Independence Blue Cross COVID Vaccination Efforts, Independence Blue Cross Information for Members, Independence response to coronavirus disease (COVID-19), Independence joins new funding initiative for area nonprofits to help vulnerable populations affected by COVID-19, Independence expands telemedicine coverage during COVID-19 outbreak, Independence provides members access to emotional wellness app at no cost, BlueCross BlueShield of Puerto Rico COVID Vaccination Efforts, BCBS Puerto Rico mobilized to fund foodbanks and reach isolated seniors, Blue Cross and Blue Shield of Rhode Island, Blue Cross & Blue Shield of Rhode Island COVID Vaccination Efforts, Blue Cross & Blue Shield of Rhode Island invests in COVID-19 relief efforts, Blue Cross & Blue Shield of Rhode Island to cover triage calls with specialists with no member cost share, BCBS of Rhode Island Information for Members, Blue Cross and Blue Shield of South Carolina, Blue Cross and Blue Shield of South Carolina COVID Vaccination Efforts, BCBS of South Carolina Information for Members, BCBS of South Carolina Coverage for Members, BlueCross BlueShield of Tennessee COVID Vaccination Efforts, BCBS Tennessee supports food banks and funds testing for vulnerable residents, How our foundation is helping local organizations fight hunger, BCBS of Tennessee Information for Members, BlueCross Tennessee to Cover Full Testing Costs for COVID-19, BlueCross Expanding Telehealth Access with In-Network Providers, Blue Cross and Blue Shield of Texas COVID Vaccination Efforts, COVID-19 Coverage For BCBS of Texas Members, BCBS of Texas Lifting Telemedicine Cost-Sharing for Fully Insured Members, Regence BlueCross BlueShield of Utah to cover cost of coronavirus (COVID-19) testing for members, Anthem Blue Cross and Blue Shield Virginia, Anthem Blue Cross and Blue Shield Virginia COVID Vaccination Efforts, Blue Cross and Blue Shield of Vermont COVID Vaccination Efforts, Premera Blue Cross COVID Vaccination Efforts, Regence BlueShield taking action to support members through coronavirus (COVID-19) outbreak, Anthem Blue Cross and Blue Shield Wisconsin, Anthem Blue Cross and Blue Shield Wisconsin COVID Vaccination Efforts, Highmark Blue Cross Blue Shield West Virginia, Highmark Blue Cross Blue Shield West Virginia COVID Vaccination Efforts, Blue Cross Blue Shield of Wyoming COVID Vaccination Efforts, Blue Cross Blue Shield of Wyoming to waive out-of-pocket costs for COVID-19 treatment, Blue Cross Blue Shield Of Wyoming Covers Corona Virus Testing Costs, BCBS of Wyoming COVID-19 Update for Providers. this.check=function(){var a=this.get(f);if(a)a=a.split(":");else if(100!=e)"v"==h&&(e=Math.random()>=e/100?0:100),a=[h,e,0],this.set(f,a.join(":"));else return!0;var c=a[1];if(100==c)return!0;switch(a[0]){case "v":return!1;case "r":return c=a[2]%Math.floor(100/c),a[2]++,this.set(f,a.join(":")),!c}return!0}; Find out if the testing provider is in your health plans network. If you have Medicare Part B (includes Medicare Advantage), you can get up to 8 free over-the-counter tests each month, until the end of the COVID-19 public health emergency on May 11, 2023. California Physicians' Service DBA Blue Shield of California 1999-2023. SECTION 2 - PATIENT INFORMATION Reason for the test cI was exposed to someone with COVID-19. You can find a list of community-based testing sites here. If a test is sold in a package of two, that is considered two tests, and you'll be reimbursed $24. COVID-19 diagnostic tests will be covered at your regular benefit level after the end of the public health emergency. Reimbursement is limited to OTC COVID-19 at-home tests authorized for emergency use by the Food and Drug Administration. California Physicians' Service DBA Blue Shield of California 1999-2023. The following claims process pertains to CareFirst commercial members* only. H0148_22_003_C_020822. You are leaving this website/app ("site"). f/4kg>/ProcSet[/PDF]>>>>stream
Online claims PO Box 272540 Once we process your claim, well mail the contract holder a reimbursement check. Find your BCBS company. Blue Shield of California has neither reviewed nor endorsed this information. Even though the Public Health Emergency is ending May 11, 2023, our commitment to helping you live your healthiest life will not change. Please enter the NDC or UPC number from the cash register receipt or test package. (To submit a single form for multiple members and/or receipts, use a mail-in form instead. Important Legal and Privacy Information|Important Information About Medicare Plans|Privacy Practices These may include your doctors office, a pharmacy or health clinic, or an urgent care center. File is in portable document format (PDF). Your member ID card is your key to using your medical plan benefits. When filing claims online, you must use a separate claim form for each receipt and for each member. If you recently visited a doctor outside of your network and you need to submit a claim, you can use one of these claim forms. Sometimes the form is called Member Application for Payment Consideration, which is the same as a claim form. testing after you received an initial COVID-19 test.
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