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  • Excellus Fap 130e 913 2014 Oe Form

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EC Instructions on last page. All Dates mm/dd/yy FORM PLEASE PRINT CLEARLY 1 Group Employer Information This section should be completed by the Group Benefits Administrator. This application cannot be processed without this information and a signature . Please use blue or black ink, print one character per box Subscriber Status: Group # Subgroup # Class# Active Retired COBRA Cancelled Please indicate reason for COBRA: Em.

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Request a Payor Payor IDPayor NameCBMA1BCBS MACBMA1MA BCBSCBMA1MA Blue Cross Blue ShieldCBMA1Massachusetts Blue Cross Blue Shield46 more rows

Payer ID - BCBSCNY: Excellus BCBS CNY. Use this payer if your practice is in the following counties: Oswego. Onondaga.

To submit a claim electronically, please login and go to Submit Claims page. Medical or Vision Claim Form - Use to submit medical services from a provider, hospital, DME vendor, etc. ... Prescription Drug Claim Form - Use for prescriptions that were purchased and/or reimbursement for covered at-home COVID-19 tests.

Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract.

To submit a claim electronically, please login and go to Submit Claims page. Medical or Vision Claim Form - Use to submit medical services from a provider, hospital, DME vendor, etc. ... Prescription Drug Claim Form - Use for prescriptions that were purchased and/or reimbursement for covered at-home COVID-19 tests.

Empire payer name and ID: Your Payer Name is Empire BlueCross BlueShield HealthPlus. Your Payer ID is 27514. Note: If you use a billing company or clearinghouse for your EDI transmissions, please work with them on which payer ID they want you to use.

Requests must be sent with the appropriate documentation to Excellus within 120 days from the date of denial in order to have the denied portion of the claim reconsidered.

Payer ID - BCBSUW: Excellus BCBS Utica/Watertown. Use this payer if your practice in the following counties: Clinton.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232