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Important information about submitting receipts

It is important to submit correct receipts with your claim. Make a copy of your receipt and send us the original receipt with your claim.


The following samples show the information your health care provider must include on your receipts. Note: These are only sample receipts. Your actual receipt may be different in form, but should always show the information identified in the examples:


 

Prescription Drugs

Prescription Drugs
  1. Name and address of provider or supplier
  2. Name of patient for whom drug is prescribed
  3. Prescription drug number and name of drug
  4. Prescribing doctor
  5. Individual charge for each prescription
  6. Date of service

If you submit a pharmacy ledger, the pharmacist's signature, provider number and the date must appear on each page. We will not accept a cash register tape.

Physician Receipt

Physician Receipt
  1. Physician's name, degree and address
  2. Full name of patient (no nicknames)
  3. Date of treatment
  4. Individual charge per treatment
  5. Actual diagnosis and description of service

Medical Supplies

Medical Supplies
  1. Name and address of provider or supplier
  2. Patient's name and address
  3. Date of service
  4. Type of service/supply
  5. Amount charged per service/supply

Outpatient Psychiatric Care

Outpatient Psychiatric Care
  1. Name and address of provider, clinic or facility
  2. Full name of patient (no nicknames)
  3. Date of treatment
  4. Individual charge per treatment
  5. Actual diagnosis and complete description of service
  6. Degree of provider/therapist level

Private Duty Nurse

Private Duty Nurse
  1. Nurse's name, degree and address
  2. Registration number
  3. Hours worked and dates of service
  4. Location of services (home or hospital)
  5. Name of patient receiving care
  6. Attending physician name and degree
Note: Must be accompanied by a complete Certification Statement. (See Benefit Information)

Chiropractic Receipt

Chiropractic Receipt
  1. Physician's name/clinic name and address
  2. Date(s) of treatment
  3. Full name of patient (no nicknames)
  4. Complete diagnosis code(s)
  5. CPT code and complete description of service
  6. Individual charge for each treatment
  7. Provider's degree title
  8. Provider identification number (PIN)
  9. Tax ID number if provider is out-of-state