Get Bi-400 - Brickstreet Insurance

Filling out the BI-400 form is an essential step in managing insurance claims with BrickStreet Mutual Insurance. This guide provides clear and comprehensive instructions to ensure users can complete the form accurately and efficiently.

Follow the steps to complete the BI-400 form successfully.

1. Click ‘Get Form’ button to obtain the required BI-400 form and access it in your preferred editor.
2. Enter the claimant name by inputting the last name, first name, and middle initial as it appears on the compensability approval letter or social security card.
3. Complete the claimant address section with the full mailing address, including street number, city, state, and zip code.
4. Provide the claimant's social security number accurately in the designated field.
5. Input the date of injury or date of last exposure. Ensure this date reflects when the injury occurred or the last exposure date for occupational pneumoconiosis claims.
6. Enter the claim number assigned by BrickStreet Insurance, which can be found on the claimant’s compensability approval letter.
7. List the diagnosis code using the appropriate ICD-9-CM numeric code alongside its description.
8. If the service requires prior authorization, provide the corresponding authorization number; skip if not applicable.
9. Check the emergency block if the services rendered were on an emergency basis.
10. Input the provider account number assigned to the claimant by the provider’s office.
11. Enter the provider's Federal Employer Identification Number (FEIN) and any required office location code.
12. If applicable, check the block indicating that payment is to be made to the claimant.
13. Provide the payee name and address if payment is being directed to someone other than the provider.
14. Fill in the service date in MM/DD/YY format.
15. Enter the procedure code corresponding to the service billed.
16. Include the modifier code if necessary.
17. Provide a narrative description of the procedure listed in the previous step.
18. Enter the total charges associated with the service rendered.
19. Indicate the number of units for the services provided.
20. Input the appropriate place of service code from the provided list based on where the service was conducted.
21. For dental claims, list the specific dental tooth number.
22. Ensure the invoice is signed by the provider or a legally responsible designee or the claimant.
23. Record the total charge, amount paid, and balance due accurately.
24. Complete the provider name and address fields to correspond with the FEIN provided.
25. Utilize the remarks field for any unusual services or fees explanations.
26. Add the provider's phone number and National Provider Identifier (NPI) for contact purposes.
27. Finally, save your work. Users can download, print, or share the completed form as needed.

Complete your BI-400 form online today for seamless claim processing.