Get Keystone Point Of Service Out Of Network Claim Form

This guide provides a clear and supportive overview on how to fill out the Keystone Point Of Service Out Of Network Claim Form online. By following the steps outlined, users can ensure all necessary information is included for efficient processing of claims.

Follow the steps to complete the claim form successfully.

1. Press the ‘Get Form’ button to access the Keystone Point Of Service Out Of Network Claim Form and open it in your document editor.
2. Fill out Section A by providing the patient’s name, identification number, and address. Make sure to include the patient's date of birth and sex, as well as their relationship to the employee.
3. In Section A, complete the subscriber’s details including their name, address, and contact numbers. Ensure to input the subscriber’s social security number, as failing to do so may delay processing.
4. Indicate if the condition was employment-related or due to an accident by selecting 'Yes' or 'No' in the appropriate fields.
5. Authorize the release of necessary information by signing the form in the designated area. This signature is required for the claim to be processed.
6. In Section B, provide the name and address of the facility where services were provided. Also, document the date of the first consultation and the date of service.
7. Detail the medical services received, including procedure codes, diagnosis codes, and charges for each service. Ensure that this information is complete and accurate.
8. In Section C, the physician's details must be filled in, including their name, address, and taxpayer ID number. The physician must also confirm the services rendered by signing the form.
9. After completing all sections, review the form for accuracy. Once confirmed, save your changes. You may download, print, or share the form as needed.

Complete your Keystone Point Of Service Out Of Network Claim Form online today for a streamlined claims process.