Here are some tips to guide you through the process of filling out your hospital confinement/outpatient surgery claim — including important information and items to have on hand before you begin.

• All sections must be completed in their entirety to ensure quicker processing.
• If this is your first time filing a hospital confinement/outpatient surgery claim, or you're filing a claim for a new diagnosis, gather copies of all the medical documentation that may be required for your condition:
  • Your name, date of birth, Social Security number (SSN) and address
  • Claimant’s name date of birth, SSN (if other than primary insured)
  • Medical documentation for your condition
  • Diagnosis (ICD9) codes
  • Signed and dated authorization
  • Date of diagnosis
• Along with your claim, please submit a copy of the itemized bill showing the admission, discharge dates and the daily room charges; a copy of the itemized surgeon's bill showing the diagnostic/procedure codes and a copy of the operative report.

Then, before you know it, you’ll start receiving the benefits you need in less time than filing by paper.

For a paper form, download, print and fax the completed document to 1-800-880-9325 or mail to P.O. Box 100195, Columbia, SC 29202-3195.

hospital confinement/outpatient surgery claim