Get Download The Smmp Claim Form - Nyc

This guide provides detailed instructions on how to fill out the Download The SMMP Claim Form - Nyc online. Following these steps will help ensure that your claim is processed smoothly and efficiently.

Follow the steps to complete the SMMP claim form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill out the member information section. This includes providing your social security number, date of birth, and selecting your status (active, retired, etc.). Ensure to include your last and first name, middle initial, address, work and home telephone numbers, city, state, zip code, and health plan information. If you have prescription drug coverage, indicate 'yes' or 'no' and attach copies of all health plan identification cards.
3. Complete the patient information section if it differs from the member information. Provide the patient's social security number, date of birth, and specify the relationship to the member. Mark whether the patient is single, married, or a child.
4. In the claim information section, fill in the dates of service, including from and to dates. Supply detailed information on services provided, including place of service, CPT/HCPCS codes, diagnosis codes, units, and charges. Ensure to list all charges appropriately.
5. Provide the member/patient's signature and release section. The member must sign all claims, unless the patient is a minor. Confirm the accuracy of the provided information. Sign and date this section.
6. Review the entire form for completeness and accuracy. Ensure all necessary documentation is attached, including proof of payment and any relevant statements from healthcare providers.
7. Once all steps are completed, save changes to the form. You can then download, print, or share the completed form as needed before submission.

Complete your SMMP claim form online today to ensure timely processing of your benefits.