Get Member Submitted Medical Claim Form - Kps Health Plans

Submitting a medical claim can seem overwhelming, but following a clear process can simplify the experience. This guide provides step-by-step instructions to effectively complete the Member Submitted Medical Claim Form for KPS Health Plans online, ensuring you understand each section and field.

Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to obtain the Member Submitted Medical Claim Form and open it for editing.
2. In the patient information section, accurately provide the patient’s name, date of birth, sex, address, relationship to the subscriber, subscriber's name, and KPS identification number as shown on the member identification card.
3. In the other health coverage section, indicate whether the patient has other coverage. If yes, prepare to attach the necessary documentation if further information is required.
4. Fill in the diagnosis section with the listed ICD-9-CM code numbers obtained from the healthcare provider, ensuring they are listed in priority order.
5. In the charges section, itemize each service. For every service, include the date of service, type of provider, place of service, description using CPT or HCPCS codes, number of days or units, charges, total charges, and total amount paid to the provider.
6. Complete the provider information with their name, address, and federal TIN or NPI. If the patient was referred, provide the referring provider's name and include any necessary documentation.
7. In the payment section, choose whether the payment goes to the patient or the provider. Be aware that proof of payment must be attached to receive payment directly.
8. Finally, sign and date the form at the bottom, certifying that the information is complete and accurate. This signature must be from the subscriber, spouse, or patient.
9. After completing the form, save any changes, download a copy for your records, and print or share the form as necessary before mailing it with the itemized bills and supporting documentation to the provided address.

Start filling out your Member Submitted Medical Claim Form online today to ensure a smooth claims process.