Get Penn Medicine Out Of Network Claim Form For Members 2016-2025

Filing an Out Of Network Claim Form can seem challenging, but with the right guidance, it can be a simple process. This guide will walk you through each section of the Penn Medicine Out Of Network Claim Form to ensure you complete it accurately and efficiently.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Provide the employee's name, date of birth, and sex in the designated fields. Ensure accuracy to prevent processing delays.
3. Enter the employee’s mailing address and daytime phone number. Indicate if there is a new address by selecting Yes or No.
4. Fill in the alternate phone number and social security number, along with the employee's ID number and plan name as specified.
5. Complete the patient’s information, including their name, date of birth, sex, relationship to the employee, and social security number.
6. Provide the provider's name, address, daytime phone number, and degree/license. This information is critical for correct processing.
7. Document the description and dates of services received. Fill in each service date along with the corresponding diagnosis codes, ensuring to use the correct ICD-10 codes.
8. List the CPT codes for each service received and their associated charges. Make sure the codes are updated per the latest AMA guidelines.
9. Both the employee and patient must sign the declaration and authorization sections. Ensure signatures are included for validation.
10. Review the completed form for accuracy and completeness. Save the changes, and download or print the form for submission.

Prepare your claim form today and ensure all sections are completed accurately for efficient processing.