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1901 Market Street, Philadelphia, PA 19103 Attention: COB Unit 17th Floor FAX: 2152382272Coordination of Benefits Questionnaire Member: Your Independence Blue Cross contract may contain a Coordination
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How to fill out coordination of benefits questionnaire
How to fill out coordination of benefits questionnaire
01
Begin by providing your personal information, including your name, address, date of birth, and contact information.
02
Fill out information about your current health insurance coverage, including the name of your insurance company, policy number, and group number.
03
Provide information about any other health insurance coverage you may have, such as through a spouse or parent.
04
Indicate whether you have Medicare or Medicaid coverage.
05
Sign and date the form to certify that the information provided is accurate.
Who needs coordination of benefits questionnaire?
01
Individuals who have multiple health insurance policies and need to determine which policy is primary and which is secondary.
02
People who are eligible for benefits through more than one health insurance plan.
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What is coordination of benefits questionnaire?
Coordination of benefits questionnaire is a form used by insurance companies to determine the primary and secondary health insurance coverage for a patient.
Who is required to file coordination of benefits questionnaire?
Healthcare providers are required to file coordination of benefits questionnaire to determine primary and secondary insurance coverage for their patients.
How to fill out coordination of benefits questionnaire?
Coordination of benefits questionnaire can be filled out by providing all relevant information about the patient's insurance coverage, including policy numbers, effective dates, and coverage details.
What is the purpose of coordination of benefits questionnaire?
The purpose of coordination of benefits questionnaire is to ensure that patients receive the maximum benefits from their primary and secondary insurance coverage.
What information must be reported on coordination of benefits questionnaire?
Information such as insurance policy numbers, effective dates, coverage details, and any other relevant insurance information must be reported on coordination of benefits questionnaire.
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