|
How To File a Claim
You may download a BlueAdvantage Administrators of Arkansas claim form in PDF (portable
document format). This file will allow you to print a copy for completing off-line.
Once the form is completed, sign and date it. Mail it to the following address:
BlueAdvantage Administrators of Arkansas
P.O. Box 1460
Little Rock, AR 72203
A separate claim form must be submitted for each patient when sending bills to BlueAdvantage.
If you have a problem downloading the form, contact
BlueAdvantage Customer Service.
The following is a breakdown of the claim form:
|
1. |
Group Number and Name |
|
2. |
Employee’s Social Security Number |
Sections 3-13 request information about the patient:
|
|
3. |
Patient’s Last Name, Complete First Name, Middle Initial |
|
4. |
Date of Birth (Month, Day, Year) |
|
5. |
Gender |
|
6. |
Patient’s Relationship to Employee (Self, Spouse, Child, Other--specify) |
|
7. |
Diagnosis or Nature of Illness or Injury |
|
8. |
Was this an accident? |
|
9. |
If yes, date of accident |
|
10. |
Was this an automobile accident? |
|
11. |
Was the illness/accident related to employment? |
|
12. |
Is patient a full-time student? |
|
13. |
If yes, what school? |
Sections 14-16 request information about the employee (contract
holder):
|
|
14. |
Employee's Last Name, First Name, Middle Initial |
|
15. |
Assignment: Payment for this claim should be made to (Hospital, Doctor, Employee) |
|
16. |
Employee Address |
Sections 17-22 request other insurance information:
|
|
17. |
Do you have other health insurance with a group or government program? |
|
18. |
Name of Insured |
|
19. |
Name and Address of Insured’s Employer |
|
20. |
Name and Address of Other Insurance Company |
|
21. |
Policy Number (other company) |
|
22. |
Type of coverage (Single or Family); Has the other insurance company paid on this
claim? If yes, submit a copy of their payment with these bills. |
|
|