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This document is intended for individuals who have coverage under Anthem Blue Cross and Blue Shield to provide information about additional health insurance or Medicare coverage they may have.

How to fill out coordination of benefits questionnaire

How to fill out Coordination of Benefits Questionnaire

1. Begin with your personal information: Fill in your name, address, and contact details.
2. Provide information about your primary health insurance: Include the name of the insurer, policy number, and type of coverage.
3. List any additional health insurance policies: Include details for any secondary insurance providers, if applicable.
4. Indicate the reason for coverage: Explain the circumstances that necessitate multiple insurance policies.
5. Fill out dependent information: Include details for any dependents that may also be covered under the policies.
6. Review your entries: Check for accuracy and completeness before submitting the form.
7. Submit the questionnaire: Follow the instructions provided to send your completed questionnaire to the relevant office.

Who needs Coordination of Benefits Questionnaire?

1. Individuals who have more than one health insurance policy.
2. Families with dependents who may be covered under different insurance plans.
3. Patients seeking to coordinate benefits between multiple insurers for maximum coverage.
4. Anyone who has recently changed insurance providers or added new policies.

For pdfFiller’s FAQs

What is Coordination of Benefits Questionnaire?

The Coordination of Benefits Questionnaire is a document used to determine the order of payment for medical claims when an individual is covered by more than one health insurance plan.

Who is required to file Coordination of Benefits Questionnaire?

Individuals who have multiple health insurance policies or have their healthcare expenses covered by different payers are required to file the Coordination of Benefits Questionnaire.

How to fill out Coordination of Benefits Questionnaire?

To fill out the Coordination of Benefits Questionnaire, individuals should provide information about all health insurance plans covering them, including policy numbers, names of insurance companies, and details of the coverage.

What is the purpose of Coordination of Benefits Questionnaire?

The purpose of the Coordination of Benefits Questionnaire is to ensure that claims are processed correctly and that payments are coordinated between multiple insurance providers to avoid overpayment.

What information must be reported on Coordination of Benefits Questionnaire?

The information that must be reported includes details about all health insurance policies, including the policyholder's name, insurance company names, policy numbers, coverage periods, and type of coverage.