Follow these steps to submit a claim based on the type of service:
Medical
Obtain the following from the provider:
Receipt of payment for services
Itemized bill that includes:
Provider first and last name
Provider address
Provider National Provider Identifier (NPI)
Provider tax identification (ID)
Place of service
Diagnosis codes and procedure (CPT) codes for each date of service
Total charge for each CPT code
Unit number (such as number of therapy visits with the provider)
Download the claim form based on your plan type:
HMO plan- Health Insurance-HMOLA claim form
Non-HMO plan- Health Insurance-Blue Cross claim form
Complete top section of claim form (Patient and Insured Subscriber Information).
You can leave the bottom section (Physician or Supplier Information) blank as this information is on the itemized bill.
Include only one member per claim form.
Include only one provider per claim form. If you received service from multiple providers, submit a separate form for each provider.
For different dates of service with the same provider, you can use the same claim form.
Example- Initial procedure and follow-up visit with the same provider can be on the same claim form.Only sign box 13 if you want payment to go to the provider.
Submit receipt, itemized bill, and completed claim form via one of the following methods:
Mail to address on claim form.
ORBring to Baton Rouge or Shreveport office lobby.
Once received, claims can take up to 30 days to process.
Pharmacy
To submit a claim to Express Scripts (ESI), follow these steps. If your plan is not through ESI, call whoever handles your pharmacy benefits.
Obtain the following from the pharmacy:
Copy of register receipt (proof of payment)
Copy of pharmacy label or printout that includes the following information:
Pharmacy name
Pharmacy address
Doctor name OR NPI
Drug name and strength
National Drug Code (NDC)
Quantity dispensed
Day supply
Rx number
Date filled
Dispense as Written (DAW) code
Amount paid for drug
Download and complete the Prescription Drug claim form.
Submit the register receipt, printout, and completed claim form to the address or fax number on the form.
Dental
To file a dental claim, call United Concordia Dental 1-866-445-5338. If your plan is not through United Concordia, call whoever handles your dental benefits.
Vision
To file a vision claim, call Davis Vision 1-800-247-9368. If your plan is not through Davis Vision, call whoever handles your vision benefits.