INSTRUCTIONS: BLUECROSS BLUESHIELD OF ALABAMA MEDICAL EXPENSE CLAIM (Form CL-438)
Alabama public employees enrolled in a state health care plan administered by BlueCross BlueShield of Alabama file the form discussed in this article when their physician or other provider does not file a claim. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 1: In box 1, enter the patient's last name, first name and middle initial.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 2: In box 2, enter your contract number as it appears on your ID card. Include any letters if applicable.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 3: In box 3, enter your group number as it appears on your ID card or your place of employment.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 4: In box 4, enter your date of birth.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 5: Indicate your sex with a check mark in box 5.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 6: In box 6, indicate the patient's relationship to the contract holder with a check mark.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 7: In box 7, enter the name, address and telephone number of the contract holder.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 8: In box 8, indicate whether the patient is covered under any other group health insurance plan with a check mark. If yes, enter the name of the policy holder, the name and address of the insuring company and the policy effective date. Indicate whether the patient is entitled to Medicare benefits under Part A or Part B with a check mark. If so, give their Medicare number.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 9: In box 9, indicate what the patient's condition was related to with a check mark.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 10: In box 10, enter the diagnoses.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 11: In box 11, enter the phone number, name and address of the ordering physician.
BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 12: Sign and date the bottom of the page.