A SEPARATE CLAIM FORM MUST BE SUBMITTED FOR EACH PATIENT WHEN SENDING BILLS TO
BlueAdvantage Administrators of Arkansas
1. GROUP NUMBER 2. MEMBER ID
& NAME NO.
3. Patient's Last Name Complete First Name Initial 4. Date of Birth
Mo. Day Yr.
5. Sex 6. Patient's Relationship to Employee
Male Female Self Spouse Child Other (Specify)
7. Diagnosis or Nature of Illness or Injury
Date Illness Began: Mo. Day Yr.
8. Was this an accident? 9. If yes, date of accident. 10. Was this an automobile 11. Was the illness/accident
accident? related to employment?
Yes No Mo. Day Yr. Yes No Yes No
12. Is patient a full time student? 13. If yes, what school?
Yes No
14. Employee Last Name First Name Initial
16. Employee Address
Street City
State Zip
15. ASSIGNMENT:
Payment for this claim should be made
to:
Hospital Doctor Employee
I hereby authorize any insurance company, prepayment organization, employer, hospital, or physician, to release
all information with respect to myself or any of my dependents which may have a bearing on the benefits payable
under this or any other plan providing benefits or services. I certify that the above information in support of this
claim is true and correct.
17. Do you have other health insurance with a
group or government program?
Yes (Please complete section below) Yes, Medicare A (Please submit your “Explanation of
No Yes, Medicare B Medicare Benefits” with these bills.)
If Medicare, reason for coverage: Over 65 Disabled Kidney Disease
18. Name of Insured 19. Name and Address of Insured's Employer
20. Name and address of other Insurance Company 21. Policy No. (other company)
22. Type of Coverage Has other Insurance Company paid?
Single Yes If yes, please submit a copy of their payment with these bills.
Family No
Date Signature of Insured
BAAA 53-03 R06/2004
PATIENT'S INFORMATIONEMPLOYEE INFORMATION
OTHER INSURANCE
P.O. Box 1460
Little Rock, Arkansas 72203-1460
GENERAL INFORMATION
1. PREPARATION OF BILLS
A. Separate bills into the following groups:
1. Physician’s Bills 3. Drug Bills or Prescriptions 4. Durable Medical 5. Ambulance Bills 7. Physical Therapy &
2. Hospital Bills Drug Claim Forms Equipment Bills 6. Nurse’s Bills Speech Therapy Bills
8. Other Bills
You should submit your bills in a timely manner. To speed the processing of your claim, all bills must be itemized and attached to the
claim form. ALL items on the claim form must be completed to insure proper payment.
NOTE: CANCELLED CHECKS, PAYMENT RECEIPTS, OR BALANCE FORWARD BILLS ARE NOT ACCEPTABLE.
HOW TO FILE A CLAIM
B. Check the bills for the following information:
1. Physician’s Bills - (Must be submitted
on physician’s Statement of Accounts
or AMA approved uniform claim form
showing physician’s social security
number or employer tax identification
number.)
a. Full name of patient
b. Date(s) of service
c. Full description of the type of
procedures, medical services
or supplies furnished for each
date
d. Amount charged for each service
e. Diagnosis
2. Hospital Bills
a. Itemized statement from hospital,
which must include diagnosis
3. Drug Bills -
a. Full name of patient
b . Date(s) of purchase
c. Prescription number
d. Amount charged for each
prescription
e. Name of drugs and diagnosis
4. Durable Medical Equipment Bills -
(Bill must include an invoice from
the supplying firm.) NOTE: On
purchase of equipment, you must
receive prior approval to be eligible
for payment.
a. Full name of patient
b. Date(s) of services
c. Description of items
d. Charge for each item
e. Must have supporting
statement from physician.
5. Ambulance Bills - (Bills must be on
ambulance firm’s letterhead.)
a. Full name of patient
b. Mileage of trip
c. Charges per mile
d. Points of departure and mileage
e. Description of other services
(i.e., oxygen, equipment, etc.)
f. Charge for each service
g. Total amount charged
6. Nurse’s Bills - (Must have signature
and registration or license number
of R.N. or L.P.N.)
a. Full name of patient
b. Professional status (i.e., R.N. or
L.P.N., etc.) of each service
c. Beginning and ending dates of
the nursing service
d. Time & number of hours worked
e. Charge for nursing service
f. Nurse’s name
7. Physical Therapy and Speech
Therapy Bills - (Must be on
therapist’s stationery.)
a. Full name of patient
b. Date(s) of service
c. Charge for each service
d. Name of licensed therapist
e. Must have appropriate evaluation
forms submitted with bills
8. Other Bills - (Must include an invoice
from the person or organization who
provided the services.)
a. Name of the person or
organization who provided
the services
b. Full name of patient
c. Date the service was provided
d. Description of services
e. Charge for each service
2. PREPARATION OF CLAIM FORM
A. Patient Information (things to remember)
1. Enter FULL name of patient; patient’s date of birth (month, day and year), and be sure to check the relationship to block.
B. Employee Information (things to remember)
1. You must enter FULL first and last name, middle initial.
2. You must enter the correct and complete Member Identification number before this claim can be processed.
3. You must enter the correct and complete address for mailing of payment.
