#Vital decisions blue cross blue shield pdf#
PDF includes the Annual Medicare Secondary Payer Employer Acknowledgement Form and Instructions for completing the form. In the absence of employer-provided employee counts, the Centers for Medicare and Medicaid Services (CMS) requires the employer group health insurance plan be considered primary to Medicare. Medicare Secondary Payer (MSP) Employer Acknowledgement Form (EAF) with Instructions
Medical Loss Ratio (MLR) Written Assurance Form – Complete this standalone form only for an existing group if one of these conditions applies: 1) the group is changing Church designation as defined by the IRS, or 2) it is a Church group wanting to change how the rebate is handled. Only BCBSOK members with the comprehensive prescription drug benefit should use this claim form to request reimbursement from a non-participating pharmacy. Not all plans cover OTC COVID-19 home test kits. If your plan does not cover, you will not be reimbursed.Ĭlaim Form – Prescription Drug (Prime Therapeutics) – SpanishĬlaim Form – Prescription Drug (Comprehensive Benefit)
Cash register receipts for OTC COVID-19 test kits may not be accepted. They must submit the pharmacy counter receipt with the completed form. Members with pharmacy benefits through BCBSOK can use this Prime Therapeutics claim form to request reimbursement after they buy a prescription drug or over-the-counter (OTC) COVID-19 home test kit. military base.Ĭlaim Form – Medical (International) – SpanishĬlaim Form – Prescription Drug (Prime Therapeutics) territory, but NOT for services obtained on a cruise ship or a U.S. Plan members can use this claim form to request reimbursement for health care services obtained when traveling internationally - when outside of the U.S.
military base.Ĭlaim Form – Medical (Domestic) – Spanish territory, when on a cruise ship, or on a U.S. Plan members can use this form to request reimbursement for health care services obtained within the U.S., a U.S. Use this form to file dental claims for reimbursement that are not filed by your dental provider. Identifies some of the most important benefit plan changes for the upcoming 2023-2024 coverage year.ĬOBRA Request for Continuation of CoverageĪpplication to request continued coverage due to employee's reduction in work hours, retirement, termination, etc.
Ģ024 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150Ģ023 Benefit Program Application (BPA) Amendment for Small Groups 2-50Įmployer Group Information (EGI) Form for Small GroupsĢ023 Benefit Program Application (BPA) for Mid-Market Groups 51-150Ģ023 Benefit Program Application (BPA) Amendment for Mid-Market Groups 51-150Įmployer Group Information (EGI) Form for Mid Market GroupsĢ023-2024 Important Small Group Benefit Changes/Uniform Modification Notice Ģ024 Benefit Program Application (BPA) Amendment for Small Groups 2-50įor renewing Small Group accounts with anniversary dates on or after use this form to amend the original BPA.Ģ024 Benefit Program Application (BPA) for Mid-Market Groups 51-150įor new Mid-Market Group accounts effective on or after. Group Enrollment Application/Change Form – SpanishĢ024 Benefit Program Application (BPA) for Small Groups 2-50įor new Small Group accounts effective on or after. Use this form to apply for group coverage or to make a change to an existing policy. And we're committed to helping you stay informed with new postings on legislative updates, new member services and programs, and more. At Blue Cross and Blue Shield of Oklahoma (BCBSOK), we are committed to providing the resources, tools and information you need to help you make the best choices for your employees and your business. Having the information you need at your fingertips is vital when making business decisions.
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