saico reimbursement form

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Claim Form To be used for out-of-network medical claims and for all dental and vision claims under the CIGNALinks. Middle East programme. Section A. Important Information Please Read Please complete and sign this claim form and submit it along with itemised bills and receipts detailing the services rendered. Send your completed form itemised bills and receipts By fax in Saudi Arabia 96614601881 in UAE 97142955231 in Bahrain 97317213915 in Qatar 9744325420 in Kuwait 9652475498 By mail SAICO...
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9 Riyadh, Kingdom of Saudi Arabia By fax: +96351855800 (telephone, fax, and/or e-mail support at the above address is not accepted) B. Required Forms: Dental and Vision Claims Section A. Description of Service(s): The claim form states the following: “This is a claim form for the claims made between [Date] and [Date] during the [service period] pursuant to the [Signaling Middle East] program.” If your claim is made between [Date] and [Date], refer to the section under A, below. Section B. The Information to Provide: All dental and prescription claim forms should include the following information: The treatment or procedure to be provided by the Service in its medical form; and Date(s) of treatment or procedure that are the subject of the claim. The following information is required in the claim form that are not contained in the information on the patient's chart: Date(s) of the treatment or procedure that are the subject of the claim. Dental claim forms should also provide: Name(s), address(BS), and Social Security Number(s), if applicable; Date of service; The service provider, or its agent, name(s), address(BS), and telephone number; and The total cost of the surgery. Medical claim forms should also include: The name of the Service provided; Date, time, and amount of service; and The medical condition, ailment, or medical treatment or procedure that affected the treatment in question. FOR/2013-148, s. 8; E.O. 13372, Apr. 23, 2013. C. Required Forms: Section C. Description of Claim: Please provide the following information in the claim form that are not contained on the patient's chart: Total cost of the care; and Dental claim forms should also provide: The name of the Service provided; Date, time, and amount of service; and The medical condition, ailment, or medical treatment or procedure that affected the treatment in question. Dental Claim Form Dental claim forms must: Include the following required claims form components: A.
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This is Allyson pigeon with practice of the practice today we're going to be going over how a health insurance claim form should look when you submit it to insurance to get reimbursed so let me say a couple of things before we jump in to how to fill out the form first I don't actually literally type into this form every time I want to submit a claim I have an electronic health record once information is in there it populates the form for me so, but I think it's important for you to sort of see what the claim form should look like so that way you can catch any potential mistakes or if there's a problem with a claim you can look at it quickly and see where maybe a mistake was made that can be corrected so let's go over this claim form for Taylor Swift, so the first part is box 1 usually what's checked is the other box is just asking what type of plan they have obviously if you're billing Medicare Medicaid you're going to check those boxes over here and then 1a is simply the ID number that's on the insurance card, so I always recommend that you get a copy of the insurance card when they come for their first visit that way if there are any issues or if you need to call the 1-800 number on the back you have that specific information for that client and then 2 3 5 a pretty self-explanatory name birthdate of the patient their address their phone number you would fill out a 4 if the client had insurance through someone else so if they have insurance through themselves you don't have to worry about that section but if they have it through a parent then or a spouse this is where you would fill in that information so in box for Taylor Swift has insurance or her dad not, so Swift get it, and so I have to fill in all his information so in box 7 I have to fill out his address his phone number over here in box 6 I don't know why it's checked other it should actually be checked child, so I'll change that and then box 11 is the group number again that's listed on the card and this is the dad's birthdate and dad's gender listed, so that's all really important that if the insurance is through someone else you need to fill in all this information so if it's not, you don't need to fill it out so for box 10 they're asking is the condition related to the following things typically for mental health counseling the answer is always no and then the other thing you have to pay attention to on this top half of the form is this 11d, so they're asking is there another health benefit plan, so this would be if somebody has both a primary and a secondary insurance so if they do obviously you'd have to check yes and then over here you'd have to write down in boxes nine a through D what the other insurance is so that could actually be a whole other blog post or video in and of itself about how to build a primary in a secondary insurance, so we're not going to get into that today but for this example I just put know she doesn't have another insurance so in boxes 12 and 13 because...
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