A Key To Your Billing Statement
Your group’s identification number
BILLING STATEMENT
The date your bill
was produced
(See Reverse For Service Information)
P.O. Box 4809 Syracuse, New York 13221-4809
Your group’s name
and address
Group
Number
A nonprofit independent licensee
of the BlueCross BlueShield Association
Date
Billed
Billing Period
From
To
Your billing period
Payments are due on or
before the due date. The
Claims Timeliness
Mandate does not allow
us to pay claims when
premium is unpaid.
Payment
Due Date
All checks will be deposited upon receipt.
This bill includes all payments and subscriber additions,
changes, and terminations processed as of
Detail of your
last bill
Includes requests to
change an
employee’s effective
or termination date
See info. next pg.
Subtotal of above
All premium
(payments) applied
since your last bill
The difference
between your adjusted
amount due and your
payment
RECONCILIATION OF PREVIOUS BILL
TOTAL BILLED
$0.00
ADJUSTMENTS
$0.00
SUBSCRIBER CHANGES
$0.00
ADJUSTED AMOUNT DUE
$0.00
PREMIUM PAID
$0.00
BALANCE
Any previous
balance
CURRENT BILLING
BALANCE FORWARD
$0.00
PREMIUM DUE
$0.00
SUBSCRIBER CHANGES
$0.00
T0TAL PREMIUM DUE
$0.00
Total number of
employees multiplied
by the rate. See
enrollment summary
of premium.
See info. next pg.
Total due...please
pay as billed
$0.00
Important: To receive proper credit return this stub to the address on reverse side
with check made payable to: Excellus BlueCross BlueShield
Do not send any other correspondence
with your payment.
Group Number
Date Billed ........
Billing Period .....
Please include your payment
stub to ensure proper credit
to your account
Payment Due Date ...
Total Premium Due ..
Enclosed Amount
$
F-130cny (Rev. 07/03)
IMPORTANT
Never send correspondence
with your stub
The reverse side of your billing statement is a valuable resource of information....... ..
Who to Call
Where Group Representatives
Should Call:
For Group Billing Statement Inquiries Only
toll free 1-888-417-9354
A Key To The Billing Statement:
Detail Statement of Changes - a list of
subscriber changes for the Previous Billing and
Current Billing. The total amount of each section
appears on page 1 of your bill.
Previous
Billing
Enrollment Summary of Premium Due - this
page summarizes the enrollment of the premium
due in the Current Billing section on page 1 of your
bill by package number, contract type and
subscriber count.
Reconciliation of Previous Billing - activity
which occurred during the previous billing period.
• Total Billed - the total premium due on your
previous bill.
• Adjustments - adjustments to previous
subscriber transactions that will affect total
billed.
• Subscriber Changes - subscriber changes
and terminations which were processed after
your previous bill was produced and before it
was paid.
A detailed listing of these changes appears
under Subscriber Changes to Previous Bill on
page 2 of your bill.
• Adjusted Amount Due - the sum of total
billed, adjustments and subscriber changes.
• Premium Paid - the amount of premium
received.
• Balance - the adjusted amount due less
premium paid.
PAYMENTS ONLY
TO LOCK BOX
ADDRESS
Excellus BlueCross BlueShield - group
P. O. Box 4752
Syracuse, New York 13221-4752
Current Billing - activity for the current billing
period.
• Balance Forward - balance from the
Reconciliation of Previous Billing.
• Premium Due - premium due for subscribers
without change in status for the current billing
period. This amount is supported by the total
premium due on the Subscriber Listing With
Premium and the Enrollment Summary of
Premium Due.
• Subscriber Changes - all subscriber additions
and subscriber changes and terminations
processed after your last bill was reconciled.
A detailed listing of these changes appears
under Subscriber Changes On Current Bill on
page 2 of your bill.
• Total Premium Due - the sum of balance
forward, premium due and subscriber
changes.
Please send all applications,
cancellation worksheets
and correspondence to us:
Attn: Membership & Billing
Excellus BlueCross BlueShield
P.O. Box 4809
Syracuse, NY 13221-4809
Current
Billing