Member Reimbursement Claim Form

Instructions for completing this form.

For FEP members please go to FEPBlue.org.

Anyone who misrepresents or falsifies essential information to receive payment requested by this form may upon conviction be subject to fine and imprisonment under applicable laws.

Loading...

Loading...

* Required Field

Enter Patient Information

  •  
  • We're unable to prepopulate the below information using ID you entered.
  •  
  • Patient ID:*
  • - -
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Patient Date of Birth: *
  • Patient Sex:*
  • Male Female
  • Patient's Relationship to Policyholder:*
  • Self Spouse Child Other
  • Patient Group ID: *
  • Group Name:

Enter Employee/Policyholder Information

  • Employee/Policyholer First Name:*
  • Employee/Policyholder Middle Initial:
  • Employee/Policyholder Last Name:*
  • Employee/Policyholder Address:*
  • Employee/Policyholder City:*
  • Employee/Policyholder State:*
  • Employee/Policyholder Zip Code:*

* Required Field

Enter Provider Information

  • Provider ID/NPI or Tax Id:
  • Rendering Provider's Name:
  • Rendering Provider's Address: *
  • Rendering Provider's City: *
  • Rendering Provider's State: *
  • Rendering Provider's Zip: *
  • Rendering Provider's Phone Number:
  • Rendering Provider's Fax Number:
  • Rendering Provider's Email Address:
  • Contact First Name:
  • Contact Last Name:
  • Contact Email Address:
  • Contact Phone Number: *
  • Enter a 10 digit phone number.
  • Contact Phone Ext:
  • Contact Fax Number: *
  • Enter a 10 digit phone number.
  1. Is the illness or injury connected to the patient's employment?
    Yes No
    Date of illness or injury Date of accident(mm/dd/yyyy)
  2. Is the claim due to an accident?
    Yes No
    Date of accident(mm/dd/yyyy)
  3. Is the claim due to an auto accident?
    Yes No
    Date of accident(mm/dd/yyyy)
  4. Is the claim related to pregnancy?
    Yes No
    Date of Last Menstrual Period(mm/dd/yyyy)
  5. Does the patient have other group coverage?
    Yes No
    Name of Insurance Company:
    Identification Number:
    Group Number:
    Amount paid by other insurance company:
  6. Is the patient eligible for Medicare?
    Yes No
    Medicare Number:
    Amount paid by Medicare (Attach copy of Explanation of Medicare Benefits) *

    Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

    To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







    Amount paid by Medicare (Attach copy of Explanation of Medicare Benefits)

    Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

    To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







  7. Describe the illness or injury for which patient received treatment: *
  • Total Charges Paid for Claim: *
  • Total Amount Patient Paid: *

Enter Claim Information

Dates of Service                  
From To Place of Service Type of Service Procedure Code (Explain Unusual Services or Circumstances) Diagnosis Code Charges Units Charge Per Unit  
Codes must be 3 - 8 characters and no decimals.

Please indicate the supporting documentation you are submitting as part of this request. *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to 816-817-5456.

Or mail to:

Blue Cross and Blue Shield of Kansas City
PO Box 419169
Kansas City, MO 64141-6169

Cancel

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

Are you having an issue with this eForm? If so click here to send us some feedback that can aide in making your experience better.

Visit BlueKC.com on your mobile device