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Print Form Coordination of Benefits / Direct Claim Form See the back for instructions. Complete all information. An incomplete form may delay your reimbursement. Member/Subscriber Information See

If your prescriber has multiple name(s) listed on the form please list the name(s) they are referring to on the form. Date of Claim. If you prefer, you can submit your claim online at this screen. This will allow for faster processing. You will be asked to provide: Your name, address, and Medicare number. Your Claim ID number. The Name(s) of both prescriber(s) and patient(s). Information regarding the reason(s) for the claim. Your name and mailing address. This letter will be sent to you when your claim is complete. There can sometimes be delays in processing claims because we receive the claim through multiple different electronic channels for submission. This can be due to a limited number of claims being reported and processed. Patient Information Your name, address, and Medicare number if you are a patient, should be filled out and submitted when your claim is complete. Please remember to include the date the claim was filed and any other pertinent information about the specific claim(s). Note: You must submit the information on the first page. The information on the second page may be incomplete. Other information and/or verification forms may be submitted on your Patient Information card. Note, these forms are available on the back of your prescription medication ID card at that time: Medication Information Card (PIC) — Your patient information card should display the following. You may check this information at any time you are enrolled in Medicare Part B in accordance with the provisions of Part B — Subscriber Requirements, or by calling Customer Support at 1-800-MEDICARE (). Patient Information Card (PIC) — Your patient information card should display the following. You may check this information at any time you are enrolled in Medicare Part B in accordance with the provisions of Part B — Subscriber Requirements, or by calling Customer Support at 1-800-MEDICARE (). Patient Information Card (PIC) — Your patient information card should display the following. You may check this information at any time you want to update: Your first and last name. Your first and last initials and one of your last three names. If you have been issued a third or second initial, then your last initial must be “A” or “E” (for individuals under 21 years of age). Your patient designation.

For pdfFiller’s FAQs

What is coordination of benefits direct?

Coordination of benefits direct (COB Direct) is a process used by health insurance providers to determine the primary and secondary coverage for an individual who has multiple health insurance plans.

Who is required to file coordination of benefits direct?

The primary insurer or the insurer that pays the claims first is usually responsible for filing coordination of benefits direct. However, it is recommended for individuals with multiple insurance plans to also inform their secondary insurer about their primary coverage.

How to fill out coordination of benefits direct?

To fill out coordination of benefits direct, the primary insurer typically provides the necessary forms and instructions. The insured individual or their healthcare provider must provide accurate information about any other insurance coverage they have, including policy details and insurance identification numbers.

What is the purpose of coordination of benefits direct?

The purpose of coordination of benefits direct is to establish the order in which multiple insurance plans should pay for an individual's healthcare expenses. This helps prevent duplicate payments and ensures that the plans work together to provide appropriate coverage.

What information must be reported on coordination of benefits direct?

The primary insurer typically requires information such as the name of the secondary insurer, policyholder information, policy details, insurance identification numbers, and any other relevant information about the secondary coverage.

When is the deadline to file coordination of benefits direct in 2023?

The deadline to file coordination of benefits direct in 2023 may vary depending on the specific insurance provider's policies. It is recommended to consult the insurance provider or refer to the relevant documentation for accurate information.

What is the penalty for the late filing of coordination of benefits direct?

The penalty for the late filing of coordination of benefits direct may differ depending on the insurance provider's terms and conditions. It is advisable to review the insurance policy or contact the insurer directly to understand the consequences of late filing.

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