Prescription Drug Claim Form - Blue Cross Blue Shield of New Mexico - sanjuancollege 2025

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Prescription Claim means any electronic or paper request for payment or reimbursement arising from retail participating pharmacies, mail-order pharmacies, and specialty pharmacies, Sample 1.
Generally, youll need to submit: The completed claim form (Patient Request for Medical Payment form (CMS-1490S) The itemized bill from your doctor, supplier, or other health care provider.
Form CMS-1696 can be downloaded at .cms.gov or obtained by calling the Customer Service number on your member ID card. The claim may be submitted via mail or fax to the address or phone number on the Medicare Part D Prescription Drug Claim Form.
In order to purchase claim forms, you should contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores. Each of the vendors above sells the CMS-1500 claim form in its various configurations (single part, multi-part, continuous feed, laser, etc).
Centers for Medicare Medicaid Services (CMS). The link on the CMS website @ . cms.gov will help you search for the forms you need. Just print the forms, fill them out, and send them to the address listed on the forms.
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Form CMS-1696 can be downloaded at .cms.gov or obtained by calling the Customer Service number on your card. The claim may be submitted via mail or fax to the address or phone number on the Medicare Part D Prescription Drug Claim Form. Reimbursement requests may be submitted up to 36 months from the date of service.

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