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Member Claim FormSutter Health PlusUse this Sutter Health Plus Member Claim Form to ask for payment for eligible care you have alreadyreceived and paid the provider of service. This includes over the counter (OTC) COVID-19 at-home testsyou purchased without a prescription at retail pharmacies, grocery stores and online.Follow the instructions below to file a claim for reimbursement of covered services. Sutter Health Plusmay delay or return your claim if information is missing. You must fill out this entire Claim Form if you paid for services. Include all requesteddocumentation (itemized bill, proof of payment) Use a separate Claim Form for each member you are submitting claims for You must confirm with the provider that he or she has not sent a claim to Sutter Health Plus foryour services. Sutter Health Plus rejects duplicate claims and this may delay payment of theoriginal claim Mail completed form and requested documentation to the address below as soon as possibleafter you receive care. You must also include any additional information we requestPlease refer to your Evidence of Coverage and Disclosure Form (EOC) for additional details on benefitsand reimbursement for services. If you have any questions about how to complete this form, please callSutter Health Plus Member Services at 1-855-315-5800.Mail your completed form to:Sutter Health PlusAttn: Claims OperationsP.O. Box 211314Eagan, MN 55121M-22-012
Section A – Subscriber InformationSubscriber ID NumberLast NameFirst NameDate of BirthMIResidential AddressCityHome PhoneMobile PhoneStateZIPSection B – Patient Information (If different from subscriber information)Last NameFirst NameMember ID NumberMIDate of BirthRelationship to SubscriberDoes the patient have other health insurance coverage?YesNo(If “Yes,” please complete all of the information below.)Name of other health insurance companyGroup NumberEmployer NamePolicy NumberHealth Insurance AddressCityStateZIPSection C – Medical InformationPlease include an itemized bill from your provider and proof of payment with this form. Each itemized billmust include: Name, address, and tax identification number of provider (doctor, hospital, lab, pharmacy) Name of the patient Description of the service(s) provided Date on which the service(s) were provided Amount charged for each service Diagnosis code for the services provided (not required for OTC COVID-19 tests) Procedure code for each of the services (not required for OTC COVID-19 tests)M-22-012Member Claim FormPage 2 of 3
Section C – Medical Information Cont.Yes1. Was this medical expense the result of an accident?2. If yes, is there a third party involved?Yes3. Was this condition or injury job related?NoNoYesNo4. Have you filed for Workers’ Compensation?Yes5. If yes, when did the injury or accident happen?DateNo6. Did you receive the services while traveling outside of the United States?7. If yes, what dates were you traveling outside of the country?8. Is this expense for OTC COVID-19 tests?YesYesNoDatesNoSection D – AgreementI certify that, to the best of my knowledge, the information on this Member Claim Form is true andcorrect. I authorize the release of any medical information necessary to process this claim.Any person who knowingly presents false or fraudulent claims for payment may be guilty of a criminalact punishable under law and may be subject to civil penalties.Authorized SignatureDatePrinted Name (First and Last)M-22-012Member Claim FormPage 3 of 3
Notice of Language AssistanceIMPORTANT: Can you read this? If not, Sutter Health Plus can have somebody help you read it. You mayalso be able to get this written in your language. For no-cost help, please call Sutter Health Plus MemberServices at 1-855-315-5800 (TTY 1-855-830-3500). (English)IMPORTANTE: ¿Puede leer esto? Si no puede, Sutter Health Plus puede proporcionarle alguien que le ayudea leerlo. También puede obtenerlo por escrito en su idioma. Llame a Sutter Health Plus Member Services al1-855-315-5800 (TTY 1-855-830-3500), sin costo alguno. �？如果不能，Sutter Health Plus ��幫助，請致電Sutter Health Plus會員服務，電話號碼1-855-315-5800 (TTY 1-855-830-3500)。(Chinese) ةمھم ةظوحلم : ص نأ ملعاف ا ًرداق نكت مل اذإ ؟اذھ ةءارق ىلع رداق تنأ لھ َ ( سالب ثلیھ رت Sutter Health Plus) نوكی دق ً صنلا اذھ ةءارق يف كتدعاسم ھنكمی ا . ضیأ كنكمی امك ً بوتكم هاقلتت نأ ا ً كتغ ُلب ا . ةدعاسم ىلع لوصحلل صخش مھیدل ةیناجم ، ص ءاضعأ تامدخب لاصتالا ءاجرب َ ( سالب ثلیھ رت Sutter Health Plus MemberServices) فتاھ ىلع 1-855-315-5800 ( يئرملا صنلا فتاھ Arabic) .(1-855-830-3500[TTY] )ԿԱՐԵՎՈՐ ՏԵՂԵԿԱՏՎՈՒԹՅՈՒՆ. Կարո՞ղ եք կարդալ սա։ Եթե ոչ, Sutter Health Plus-ը կարող էտրամադրել մեկին, ով կօգնի Ձեզ կարդալ այն։ Դուք կարող եք նաև ստանալ այն գրված Ձեր լեզվով։Անվճար օգնության համար խնդրում ենք զանգահարել Sutter Health Plus-ի Անդամների սպասարկմանբաժին՝ 1-855-315-5800 (TTY 1-855-830-3500) հեռախոսահամարով։ (Armenian)សារៈសំខាន់៖ �ដីនេះឬទេ? បើសិនមិនអាចទេ Sutter Health Plus �ួយអានវាជូនអ្នក ។ ។ �ស់ថ្លៃ សូមទូរស័ព្ទទៅ ផ្នែកសេវាសមាជិក Sutter Health Plus តាមលេខ 1-855-315-5800 (TTY1-855-830-3500)។ (Cambodian) مهم هتکن : ديناوت یمن رگا ؟ديمهفب و ديناوخب ار بلاطم نيا ديناوت یم ايآ ، Sutter Health Plus یدرف زا دناوت یم دناوخب ناتيارب ارنآ ات دريگب کمک . دراد دوجو یسراف نابز هب بلاطم نيا همجرت ناکما نينچمه . تامدخ تفايرد یارب ناگيار کمک و ، یاضعا تامدخ رتفد اب افطل Sutter Health Plus نفلت هرامش اب 1-855-315-5800 (TTY 1-855-830-3500) (ديريگب سامت Farsi).महत्वपूर्ण: क्या आप इसे पढ़ सकते/सकती हैं? यदि नहीं, तो सट्टर हेल्थ प्लस इसे पढ़ने में किसी से आपकीसहायता करवा सकता है। आप इसे अपनी भाषा मे भी लिखवाने में समर्थ हो सकते/सकती हैं। निःशुल्क सहायताके लिए, कृपया 1-855-315-5800 (TTY 1-855-830-3500) पर सट्टर हेल्थ प्लस मेंबर सर्विसेस को कॉल करें।(Hindi)LUS TSEEM CEEB: Koj nyeem puas tau tsab ntawv no? Yog koj nyeem tsis tau, Sutter Health Plus muajneeg pab nyeem rau koj. Tsis tas li ntawd xwb, peb tuaj yeem muab sau ua hom lus koj nyeem tau rau kojtib si. Yog koj xav tau kev pab pub dawb, thov hu rau Sutter Health Plus Lub Chaw Pab Cuam Tswv Cuabntawm tus xov tooj 1-855-315-5800 (TTY 1-855-830-3500). ��ができます？読めない場合は、Sutter Health Plus ��料のご相談は、Sutter Health Plus Member Services、電話: 1-855-315-5800 (TTY 1-855-830-3500) まで。(Japanese)
중요: 귀하는 이것을 읽으실 수 있습니까? 만약 읽으실 수 없다면, Sutter Health Plus 에서 다른 사람에게 부탁하여 그것을 읽으실 수 있도록 도와드릴 수 있습니다. 또한 이것을 귀하의 사용 언어로 작성해 받으실 수도 있습니다. Sutter Health Plus 회원 서비스 1-855-315-5800 (TTY 1-855-830-3500)에 전화를 하시어 무상으로 도움을 받으십시오. (Korean)ໝາຍເຫດ: �ສະບັບນີ້ບໍ່? �້, ທາງ Sutter Health Plus �ນໃຫ້ທ່ານ. ນອກຈາກນັ້ນ, ��ຫ້ທ່ານອີກດ້ວຍ. ��ສຍຄ່າບໍລິການ, ກະລຸນາຕິດຕໍ່ ໜ່ວຍບໍລິການ ຂອງSutter Health Plus ທີ່ໝາຍເລກໂທລະສັບ 1-855-315-5800 (TTY 1-855-830-3500). (Laotian)ਅਹਿਮ: ਕੀ ਤੁਸੀਂ ਇਸ ਨੂੰ ਪੜ੍ਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹੀਂ ਤਾਂ, Sutter Health Plus (ਸੱਟਰ ਹੈਲਥ ਪਲਸ) ਕਿਸੇ ਤੋਂ ਇਹ ਪੜ੍ਹਨਵਿੱਚ ਤੁਹਾਡੀ ਮੱਦਦ ਕਰਵਾ ਸਕਦਾ ਹੈ। ਤੁਸੀਂ ਇਸ ਨੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਵਿੱਚ ਵੀ ਲਿਖਵਾ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਮੱਦਦ ਲਈ ਕਿਰਪਾ ਕਰ ਕੇSutter Health Plus Member Services ਨੂੰ 1-855-315-5800 (TTY 1-855-830-3500) ਉਤੇ ਕਾਲ ਕਰੋ। (Punjabi)ВАЖНО: Вы можете это прочитать? Если нет, Sutter Health Plus может предоставить Вам кого-то,кто сможет помочь Вам прочитать это. Вы также можете получить это в письменной форме насвоем языке. Для бесплатной помощи позвоните в Службу поддержки членовSutter Health Plus по телефону 1-855-315-5800 (TTY 1-855-830-3500). (Russian)MAHALAGA: Nababasa mo ba ito? Kung hindi, maaari kang bigyan ng Sutter Health Plus ng taong babasa para sa iyo. Maaari mo ding hilingin na isulat ito sa iyong wika. Para sa walang-gastos na tulong,mangyaring tumawag sa Sutter Health Plus Member Services sa. 1-855-315-5800(TTY 1-855-830-3500). (Tagalog)สำ คัญ: คุณอ่ำ นออกหรือไม่ ถ้ำ อ่ำ นไม่ออก Sutter Health Plus สำ มำ รถให้คนมำ ช่วยคุณอ่ำ นได้ นอกจำ กนี้ คุณยังสำ มำ รถขอรับเนื้อหำ นี้เป็นภำ ษำ ของคุณได้อีกด้วย หำ กต้องกำ รควำ �ีค่ำ ใช้จ่ำ ยกรุณำ โทรหำ Sutter Health Plus Member Services ที่ 1-855-315-5800 (TTY 1-855-830-3500) (Thai)QUAN TRỌNG: Qu. vị có thể đọc thông tin này không? Nếu không, Sutter Health Plus có thể yêu cầu aiđó đọc giúp cho qu. vị. Qu. vị cũng có thể nhận được thông tin này dưới dạng văn bản bằng ngôn ngữcủa qu. vị. Để được hỗ trợ miễn phí, vui lòng gọi cho ban Dịch Vụ Thành Viên củaSutter Health Plus theo số 1-855-315-5800 (TTY 1-855-830-3500). (Vietnamese)
Sutter Health Plus Use this Sutter Health Plus Member Claim Form to ask for payment for eligible care you have already received and paid the provider of service. This includes over the counter (OTC) COVID-19 at-home tests you purchased without a pres
