Get Medical Claim Form - Excellus Bluecross Blueshield

Filling out the Medical Claim Form for Excellus BlueCross BlueShield can be straightforward when you know the steps to follow. This guide will provide you with clear instructions to ensure you complete the form accurately and effectively.

Follow the steps to successfully complete your Medical Claim Form.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering your Excellus Medicare ID number in the designated field. You can find this information on your ID card.
3. Complete the member information section. Fill in the member's last name, first name, street address, city, state, and zip code.
4. Enter the member's date of birth in the required format (MM/DD/YYYY).
5. Answer the question regarding expenses related to a motor vehicle or work-related accident by selecting 'Yes' or 'No'. If 'Yes', provide the date of the accident or injury in the specified format.
6. Indicate whether you have other health insurance. If applicable, provide the name of the other insurance company and the policy number.
7. In the certification section, read the statement carefully and, if you agree with the terms, sign and date it. Fill in your phone number, including the area code.
8. Ensure that you have all original itemized receipts ready. These receipts should include the patient's full name, type of service, place of service, date and charge for each service provided, patient diagnosis, and any necessary translations for services not rendered in the USA.
9. Make copies of your original receipts for your records before submitting them with the claim form.
10. After reviewing your completed form for accuracy, submit the form along with all itemized bills to the address provided: Excellus BlueCross BlueShield, P.O. Box 22999, Rochester, NY 14692.

Start completing your Medical Claim Form online today for a seamless submission experience.