IMPORTANT: Please Read the Following Before Completing This Form

HARRINGTON HEALTH (NEIC #95266)

HEALTH BENEFIT CLAIM FORM ___ Group Number Q-9

Claims Processor forKaiser PermanenteAlternate Mental Health, Supplemental Medical and PPO Plans

IMPORTANT: Please read the following before completing this form. Please print in ink.
Submit one claim form per patient. All questions must be answered for prompt processing. Attach itemized bills from your hospital, doctor, or pharmacy. The bills should include the patient’s name, diagnosis, date of service, type of service and charge. Keep a copy of this completed form and bills for your records.
Note: All claims must be submitted within one year from date of service.
Send this completed form to: Harrington Health (HH) – Payor ID #95266
PO Box 30537
Salt Lake City, UT84130-0537
Fax Number: 1-877-779-9873 Customer Service Number: 1-800-216-2166
EMPLOYEE/RETIREE DATA
NAME OF YOUR EMPLOYER / WORK PHONE NUMBER:
( ) / HOME PHONE NUMBER:
( )
EMPLOYEE LAST NAME / EMPLOYEE FIRST NAME / MIDDLE INITIAL / EMPLOYEE SS NUMBER
HOME ADDRESS - STREET / CITY / STATE / ZIP CODE
PATIENT DATA
PATIENT LAST NAME / PATIENT FIRST NAME / MIDDLE INITIAL / SEX Male
Female
DATE OF BIRTH: / AGE: / DISABLED DEPENDENT: Yes No
RELATIONSHIP TO EMPLOYEE/RETIREE:
Husband Wife Domestic Partner Son Daughter Other, please describe:
If this patient is a dependent child 18 or older, is child enrolled as a full-time student? Yes No
Were these charges incurred as a result of an on-the-job illness or injury? Yes No Other Accident? Yes No
If claim is the result of any kind of accident or injury, complete the following information: Date:______Time: ______
Description of what happened:
OTHER INSURANCE DATA -PLEASE READ INSTRUCTIONS ON BACK
IS THIS PATIENT EMPLOYED?
Yes No / IF YES, GIVE NAME AND ADDRESS OF EMPLOYER:
IS THIS PATIENT OR ANY FAMILY MEMBER COVERED BY OTHER GROUP HEALTH INSURANCE? Yes No
If yes, please complete below:
Name of Insured / Name/Address of Insurance Company / Certificate/Group Number
IS THIS PATIENT COVERED BY MEDICARE?
Yes No / PLEASE MAKE PAYMENT DIRECTLY TO:
My Hospital My Doctor Me Other: ______
PLEASE SIGN BELOW TO AUTHORIZE PAYMENT
Signature of Employee/Retiree:______Date:______
I certify this information is correct and authorize its release for the administration of this claim and for health care research and evaluation if not individually identifiable.
Signature of Patient (Parent, if minor) ______Date:______
PHYSICIAN OR SUPPLIER INFORMATION
DIAGNOSIS OR NATURE OF ILLNESS/INJURY: RELATE ITEMS 1- 4 TO THE DIAGNOSIS CODE BY ENTERING THE ITEM # FOR EACH SERVICE
DATE OF SERVICE
(From/Through) / COMPLETE ADDRESS OF SERVICES RENDERED / PROCEDURES, SERVICES OR SUPPLIES CPT/MODIFIER / DIAGNOSISCODE / FULLY DESCRIBE PROCEDURE / DAYS/ UNITS / CHARGES
/ / $
/ / $
/ / $
/ / $
PHYSICIAN/SUPPLIER FEDERAL TAX I.D. NUMBER
SSN EIN / PATIENT’S ACCOUNT NUMBER / TOTAL CHARGES
$ / AMOUNT PAID
$ / BALANCE DUE
$
SIGNATURE OF PHYSICIAN/SUPPLIER – INCLUDE DEGREES/CREDENTIALS
SIGNED DATE / PHYSICIAN’S/SUPPLIER’S BILLING NAME, ADDRESS, ZIP CODE & PHONE NO.

If the patient has coverage under any other group insurance plan or government plan, you may be able to receive benefits under both plans and should submit your claim using the following guidelines. This will happen if both you and your spouse or domestic partner (where applicable) work and both of you carry family coverage through your respective employers. In addition to the information you’ll need from the other insurance plan described below, be sure to attach a Harrington Health claim form and copies of itemized bills and receipts.

1)If you (the employee) are the patient:

a)Send the original claim to Harrington Health. Keep a copy.

b)After receiving Harrington Health’s payment, send a copy of the original claim and a copy of the Explanation of Benefits to the other insurance company.

2)If your spouse or domestic partner (where applicable) is the patient: His/Her insurance should pay first.

a)Send the original claim to the other insurance company. Keep a copy.

b)After receiving the other insurance payment, send a copy of the original claim to Harrington Health along with their Explanation of Benefits.

3)If your child is the patient and you, the employee, have a birthday which falls earlier in the year than your souse or domestic partner (where applicable), Harrington Health should pay first.

4)If your child is the patient and your spouse or domestic partner (where applicable) has a birthday which falls earlier in the year, Harrington Health should pay second and your spouse’s coverage should pay first.

5)For dependent children of separated or divorced parents, the parent with custody generally pays first. Then, if the parent remarries, the new spouse’s plan pays second. The parent without custody pays last. This rule takes precedence over rules 3 and 4 above.

HH Generic Claim Form rev (04/12)