Get Out Of Network, Keystone Pos Plan, Clain Form

Filing a claim for services rendered under the Out Of Network, Keystone POS Plan can seem daunting. This guide is designed to walk you through the online process step-by-step, ensuring that you complete the Claim Form accurately and efficiently.

Follow the steps to fill out the Claim Form online.

1. Click ‘Get Form’ button to obtain the Claim Form and open it in the preferred document editor.
2. Fill in Section A by providing necessary personal information: - Write the patient’s name (first, middle initial, last) in the designated field. - Enter the ID number associated with the patient. - Provide the patient’s address, including city, state and zip code. - Insert the patient’s date of birth formatted as month/day/year. - Indicate the patient’s sex by checking the appropriate box (M or F). - State the patient’s relation to the employee (self, spouse, child, etc.).
3. Complete the subscriber’s information: - Fill in the subscriber’s name (first, middle initial, last) and address. - Include the subscriber’s social security number, as this is crucial to avoid processing delays.
4. Provide details regarding the nature of the medical condition: - Answer whether the condition was related to the patient’s employment or an accident, checking 'yes' or 'no' as appropriate. - If an accident occurred, provide a description and any relevant incident details.
5. In Section C, ensure your physician or supplier completes their information: - They should fill in their details, including name, address, and taxpayer ID number for reporting purposes. - Be sure they document the services provided, including diagnosis codes, procedure codes, and charges.
6. Sign and date the form where indicated, making sure all required sections are completed to avoid delays.
7. Once all sections are completed, you can save changes, download, print, or share the form as needed.

Complete your Out Of Network, Keystone POS Plan, Claim Form online today to ensure a smooth claims process.