A claim is a description of services that a member has received from a primary care physician or other medical professional (sometimes referred to as provider).
How to submit a claim
For most HMO members you are not involved in the claims process unless you receive care outside of your IPA. When you receive care within your IPA almost all claims are processed by your primary care physician's IPA or medical group.
However, physicians often send the same information to our patients, and you may receive a bill.
If you receive a bill from the provider and have questions, call the provider first as he or she can best answer your question.
If you need help understanding the billing process, please call us at the Member Services number on your Blue Shield ID card.
How to correct a claim
If the information in a claim is not accurate, please contact your provider's office. The provider will need to resubmit a bill with the correct information.
How to appeal a claim
Every claim is processed in accordance with the services reported and the benefits, exclusions and limitations of your health plan.
If your claim was denied and you believe that additional information will affect the processing of the claim, contact us.
If you are not satisfied with your response at that point, you may file a grievance.