Sample ID card and description of terms e Back left Back right

Sample ID card and description of terms
Back left
Back right
Front left
Front right
blueshieldca.com
Providers: Please file all claims with your local
BlueCross BlueShield licensee in whose
service area the member received services or,
when Medicare is primary, file all Medicare
claims with Medicare.
California Providers: Call Provider Customer
Service to obtain medical and hospital
admission prior authorization to avoid reduced
or non-payment; Pharmacistscall for
prescription processing information. Visit
Provider Connection at:
blueshieldca.com/provider.
CA Medical claims to:
Blue Shield of California, P.O. Box 272540,
Chico, CA 95927-2540
(800) 642-6155 Member Services
(800) 241-1823 TTY
(877) 263-9952 Mental Health Customer Svc.
(877) 304-0504 NurseHelp 24/7
(800) 985-2405 LifeReferrals 24/7
(800) 810-2583To locate providers outside of
California
(800) 541-6652CA Provider Customer Service
(including hospitals)
(888) 635-8224 Pharmacists Only
Blue Shield of California is an independent
member of the Blue Shield Association.
Blue Shield of California
a
b
c
d
Subscriber
JOHN DOE
ID# XEHJ02388023
Copayments
Office
$25
Hospital
$200
Emergency$100
e
g
Group #
Effective
Plan
H12187
01/01/13
HMO
Rx
Yes
f
SF HEALTH SERVICE SYSTEM
Back left
This information is used by physicians
and providers.
Back right
Member services numbers and addresses
to submit claims.
Front left
a Member name – your name
b Member ID number
cPCP/SPC – indicates the primary care
physician (PCP)/ specialist (SPC) office
visit copays
dER – indicates emergency room
(ER) copay
Front right
eGroup# and Plan – shows type of
coverage
fEffective date – the date you became
covered by our plan
gThis information is required by
pharmacies to electronically bill
prescriptions.
blueshieldca.com/sfhss
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MEDICAL GROUP NAME
JANE DOE, MD
(415) 123-4567
JOHN DOE
Effective 01/01/13
k
JOHN DOE, JR.
Effective 01/01/13
Members:
In case of emergency, call 911 or
seek appropriate emergency care. As
soon as possible after receiving care,
please contact your personal
Physician.
Carry this ID card with you at all
times and present it to your Personal
Physicianwhenever you receive
care.
It is important to follow the
procedures explained in your
Evidence of Coverage booklet. If
you have any questions about your
benefits, your copayments,or your
prescription drug coverage, call
Member Services.
A+ gives you the option to self-refer to an Access+ Specialist, subject to certain limitations.
See your Evidence of Coverage for details.
Inside right
This information is for you to read in case of
emergency, if you are billed in error or need
help locating network pharmacies.
A45760 (4/13)
Inside left
j Name of your Personal Physician
k Name of your medical group or IPA
An Independent Member of the Blue Shield Association
j
Inside right
Sample ID card and description of terms
Back left
Back right
Front left
Front right
blueshieldca.com
PhysiCians and Providers:
<plan name> (HMO) Member Services
Prior approval: Telephone the physician named on
this card prior to treatment in a non-emergency.
Provision of routine treatment without prior
authorization may result in non-payment.
Note: This card is for identification only.
emergency care: Telephone the physician named
on this card as soon as possible after treatment.
note: This card is for identification only. Call
the number on the reverse side of this card
to verify eligibility.
PhysiCians and Providers:
(877) 654-6500
elibility verification
Blue Shield of California is an independent
member of the Blue Shield Association.
(800) 776-4466
(800) 794-1099 TTY
submit Medical claims to:
Blue Shield 65 Plus
P.O. Box 272640
Chico, CA 95927-2640
submit rx claims to:
Blue Shield of California
Pharmacy Services
P.O. Box 7168
San Francisco, CA 94120-7168
i
Back left
This information is used by physicians
and providers.
Back right
Member services numbers and addresses
to submit claims.
i Address for you to send out-of-network
prescription claims to
a
b
Member
c
Copayments
PCP/SPC $XX/XX
ER
$XXX
$XXX
AMB
d
John doe
Membership number
XeaJ1234567801
e
g
Plan
Group No.
Card issued
Plan code
<plan name> (hMo)
Mrd100
12/1/12
Bs1
RxBin
RxPCN
Issuer
012353
01920000
80840
CMS H0504-015
f
h
Front left
a Member name – your name
b Member ID number
c PCP/SPC – indicates the primary care
physician (PCP)/ specialist (SPC) office
visit copays
Note: Refer to your Evidence of Coverage
for complete benefit information. The
information provided on your ID card
is to be used as a quick reference only.
Benefits are not limited to this information.
d ER – indicates emergency room
(ER) copay
e AMB – indicates ambulance
(AMB) copay
Front right
f Group No. and Plan – shows type
of coverage
g Card issued – the date your most recent
card was issued to you
h This information is used by pharmacies to
electronically bill prescriptions.
H0504_12_364 10152012
blueshieldca.com
Inside left
MEMBERS:
John doe, Md
(555) 555-5555
(877) 304-0504 NurseHelp 24/7
(800) 855-2881 TTY
ABC Medical Grp
123 Main St
Anytown, CA 00000
in an emergency: Call 911 or
immediately go to the nearest
hospital emergency room for
treatment.
HOSPITAl INFORMATION:
out-of-area urgent care: If you are
outside the health plan area and
need medical attention right away
for an unforeseen illness or injury,
go to the nearest medical facility.
Notify Blue Shield 65 Plus or your
primary care physician at the time
of service or as soon as possible
after treatment.
aBC hospital
(555) 555-5555
123 Main St
Address line 2
Anytown, CA 00000
Inside left
j Name of your primary care physician
k Name of your medical group or
Independent Practice Association (IPA)
l
Billing and member services:
Network providers have agreed not
to bill Blue Shield 65 Plus members.
Contact Member Services if you are
billed in error or if you need other
assistance with claims or billing.
For information on locating network
pharmacies: Call Blue Shield 65 Plus
Member Services.
Inside right
This information is for you to read in case of
emergency, if you are billed in error or need
help locating network pharmacies.
Hospital name and address
A35138 (10/12)
l
PHYSICIAN INFORMATION:
An independent member of the Blue Shield Association
j
k
Inside right
Sample ID card and description of terms
Front
Back
blueshieldca.com
a
b
Member
John Doe
c
Plan
Card issued
<plan name> (PDP)
12/15/12
Submit Rx claims to:
Blue Shield of California
Pharmacy Services
P.O. Box 7168
San Francisco, CA 94120-7168
Membership No.
XEAJ1234567801
RxBin
RxPCN
RxGrp
Issuer
012353
03510000
MRD300
80840
CMS S2468-004
e
<plan name> (PDP) Member Services
(888) 239-6469
(888) 239-6482
Blue Shield of California is an independent
member of the Blue Shield Association.
Member Services
TTY
f
d
Front
a Member name – your name
b Member ID number
c Card issued – the date your most recent
Back
e Address for you to send out-of-network
prescription claims to
f Member Services toll-free number
card was issued to you
An independent member of the Blue Shield Association
to electronically bill prescriptions.
A35145 (10/12)
d This information is used by pharmacies
S2468_12_364 10152012
blueshieldca.com