Medicare Advantage members: Use the claims form for OTC at-home tests with a healthcare provider order. Required documentation for this medical claim includes: The attestation included in our claims process ensures our members comply with the spirit of this policyto ensure tests are accessible and affordable for those who need them. For additional COVID-19 information, visit the Blue Cross Blue Shield Coronavirus Resource Center. Costco, Wal-Mart, Amazon), please attach itemized register receipts to the back of this form. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. The Biden administration announced that it intends to end the COVID-19 national and public health emergency (PHE) declarations on May 11, 2023. Some testing locations may not be in your health plans network. Each test within a package is counted individually. [CDATA[ For more information, view our privacy policy. For example, a physician, a nurse practitioner, or a physician assistant. W006259 COVID-19 Testing Member Reimbursement Form - Non-Medicare Advantage Please use this form to request reimbursement for COVID-19 tests you have paid for out of your own pocket. // Coronavirus (COVID-19) Updates | Blue Cross Blue Shield endstream endobj 462 0 obj <>/ProcSet[/PDF]>>>>stream Coverage varies by plan type. Also, note that all American households can order free COVID-19 tests from the federal government. If you have any questions about your over-the-counter test, you should call your healthcare provider or check out our FAQs.
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