PO Box 91059
VISION
Seattle, WA 98111-9159 Member Claim Form
for Microsoft
This form is to be used for Vision claims (routine exam and hardware) where you incurred expenses from a
provider who did not bill the plan directly.
For Medical or Dental claims within the United States, please use the Medical/Dental Member Claim
Form for Microsoft.
For Prescription claims, please use the Prescription Drug Reimbursement Form (primary and
secondary coverage).
For services outside of the United States, please use the Member International Claim Form for
Microsoft.
See instructions on the next page for additional information to complete your claim. Premera Blue
Cross will not pay a bill submitted more than 12 months after the date of service.
1. Patient / Member
Premera Blue Cross ID card number Group number Prefix
1000010
Patient/Member name (first, middle, last) Relationship to subscriber
Subscriber name (first, middle, last) Patient date of birth (month/day/year) Home phone number
Address City State ZIP
Email (optional) Cell phone number (optional) Work phone number (optional)
Does the patient have vision coverage from any other health plan?
No, skip to section 2 Yes, please attach the Explanation of Benefits (EOB) statement from the primary plan with this claim, and complete the following information.
Name of other health coverage plan ID number or policy number of other health plan Phone number of other health plan
2. Claim Details NOTE: You must submit an itemized bill that shows the total amount you paid to the provider or your claim will be returned.
Vision claim payments will be made to the patient/member.
What services were performed (check all that apply)?
Routine exam Hardware (glasses/contacts)
3. Signature
To be accepted, this form must be fully completed (as appropriate to the claim being submitted), signed, and have itemized bill attached.
Mail to: Premera Blue Cross, P.O. Box 91059, Seattle, WA 98111-9159 or Fax to 800-676-1477 or email to: [email protected] (from
the Microsoft email alias only)
Please note: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines, and denial of insurance benefits.
Patient signature (or legal guardian if patient cannot legally consent to services) Relationship to patient Date (month/day/year)
Self
Other:
031371 (02-28-2019)
An Independent Licensee of the Blue Cross Blue Shield Association
Instructions
A. Complete a claim form. Most providers will bill directly for you and no claim form will be necessary. However, if you do incur
expenses from a provider who will not bill the plan directly, you will need to complete a claim form and provide an itemized bill.
(See “C” for more information about itemized bills.)
B. If you have other coverage, attach a copy of the bills you submitted to the other plan and an Explanation of Benefits (EOB)
you received from the other plan.
C. Attach the itemized bill. Please do not highlight or modify the itemized bill as this may cause delayed processing of
your claim. Please note: Your claim will be returned if all of the information required below is not included. One member per claim
form. The form is not valid unless signed.
The itemized bill must contain all of the following information:
Name of the patient/member who incurred the expense.
Name, address and IRS Tax Identification Number (TIN) of the provider. (Note: Vision hardware does not need a TIN)
Date of service and itemized charge for each service rendered and/or item purchased.
The full amount you paid to the provider. (Note: If your receipt only includes the deposit amount and not the total price of your
hardware and/or lenses, only the amount listed on your receipt will be considered for reimbursement. If you wish to be
considered for reimbursement for the full amount of your hardware and/or lenses your receipt must reflect the full payment.)
D. The front of your member ID card may not match the card pictured below. This sample card is meant to be a guide to help
you locate your identification number.
1 — Prefix and Identification # help us verify your eligibility,
determine your coverage and process claims.
2 — Group # identifies your plan’s benefits.
E. Send the completed claim form and bills to:
Premera Blue Cross Customer Service: 800-676-1411
P.O. Box 91059 Fax: 800-676-1477
Seattle, WA 98111-9159 Email:
[email protected] (from the Microsoft email alias only)
Please note: Premera Blue Cross will not pay a bill submitted more than 12 months after the date of service.
