Filing Requirements:
Any claim filed without the required documentation listed above will be returned.
• Visit BlueCrossNC.com for prescription drug, dental and international claim forms, or call the toll-free number
on your ID card.
• Complete a separate claim form for each covered family member.
• Enclose itemized receipts and make copies for your records. Procedure codes and diagnosis codes are required.
Please obtain codes from your provider. See Section IV for required information.
• Do not file a claim if the provider is filing for the same services.
• Attach Explanation of Benefits if these services are covered by another insurance policy.
• Claims must be filed within 18 months from the date services were received, or they will be denied.
• Please see Section VI for mailing information.
Member Claim Form
Do not file prescription drugs on this form. Type or use blue or black ink to complete.
BLUE CROSS
®
, BLUE SHIELD
®
and the Cross and Shield symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is
an independent licensee of the Blue Cross and Blue Shield Association. BE236, 10/18
SECTION I: Patient Information Please enter the subscriber number from your ID card.
SECTION III: Other Insurance Information
Please complete the information below if the patient is covered by another health insurance policy.
PLEASE NOTE: If your other insurance or Medicare policy is primary, you must attach a copy of the Explanation
of Benefits from that insurer. Your claim cannot be processed without this information.
SECTION II: Mailing Information Please check here if address has changed.
Please complete the information below if the patient is covered by Medicare:
Subscriber
Number:
Does the patient
have other insurance?
Patient’s Last Name:
Subscriber Name:
Address (Line 1):
Address (Line 2):
City: State: Zip Code:
Other health insurance
company name:
Medicare health insurance
claim number:
Other policy
number:
Other policy holder’s
employer name:
Other policy
holder’s name:
First Name:
Male
Female
Middle Initial:
2 digits following member’s
name (see ID card)
Begin with
letter prefix
Date
of Birth:
Relationship
to Subscriber:
Sex:
Yes
No
Is patient
eligible for:
Part A
Part B
Part A and B
Self
Spouse
Child
Other:
BlueCrossNC.com
