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Code Description Effective Date Deactivation Date Last ...
Code Description Effective Date Deactivation Date Last Modified Date Notes 1 Deductible Amount 1/1/1995 2 Coinsurance Amount 1/1/1995 3 Co-payment Amount 1/1/1995 4. The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy
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Prescription Drug Claim Form - bcbsal.org
www.bcbsal.orgDo not attach prescription receipts if you complete this form in its entirety. 6. Mail this claim form to the address shown below: Blue Cross and Blue Shield of Alabama Attention: Prescription Drug Claims PO Box 830280 Birmingham, Alabama 35283-0280 — OR — For fastest processing you may submit your claim on-line by visiting . AlabamaBlue.com
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www.bcbsal.orgMEDICAL EXPENSE CLAIM FILL OUT A SEPARATE FORM FOR EACH PATIENT. Use this form to file a claim for any eligible medical expenses when your physician or other provider does not file a claim. Please print clearly with black ink or type. 1. Patient’s Name (only one Patient per form) 2. Contract Number as shown on your I.D. Card
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