Fillable Member Claim Form Requirements (BlueCross BlueShield of North Carolina)

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Member Claim Form Requirements (BlueCross BlueShield of North Carolina)

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  • 28 other fields

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Member Claim Form Requirements
Please note the below filing requirements and tips for filling out the attached Member Claim
Form. Do not file prescription drugs or dental claims with this form.
Visit BlueCrossNC.com/Claims for prescription drug, dental and international claim forms, or call the toll-free number
on your ID card.
Important Notes When Completing the Claim Form:
• Type or use blue or black ink to complete.
• Complete a separate claim form for each covered family member.
• Complete a separate claim form for each provider.
• Attached receipts must include procedure codes and diagnosis codes, such as CPT/Dx code as well as tax ID and
individual cost for each service/name of the provider as well as the provider’s address.
• Do not file a claim if the provider is filing for the same services or if the provider is in-network.
• 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.
• If your address has recently changed, please contact Customer Service using the phone number located on the back of
your ID card to ensure our records are accurate.
• Keep a copy of this form and your receipts.
• Remember to sign and date at the bottom of Section 5.
Please note: Claim form will be returned to member if provider receipts are not attached with the form!
BlueCrossNC.com
Member Claim Form
SECTION 1: Patient Information Please enter the subscriber number from your ID card.
Subscriber
Number:
Begin with
letter prefix
2 digits following member’s
name (see ID card)
Patient’s Last Name: First Name: Middle Initial:
Date
of Birth:
Sex:
Male
Female
Relationship
to Subscriber:
Self
Spouse
Child
Other:
SECTION 2: Mailing Information
Subscriber Name:
Address (Line 1):
City: State: Zip Code:
SECTION 3: Other Insurance Information
Please complete the information below if the patient is covered by another health insurance policy.
Does the patient
have other insurance?
Yes
No
Other health insurance
company name:
Other policy
number:
Other policy
holder’s name:
Other policy holder’s
employer name:
Please complete the information below if the patient is covered by Medicare:
Medicare health insurance
claim number:
Is patient
eligible for:
(check all that apply)
Part A
Part B
Part C
SECTION 4: International Information
Please complete the information below if the provider or services rendered were out of the United States.
Country: Currency Used:
BlueCrossNC.com
SECTION 5: Submitting Form Information
MAIL THIS FORM, ITEMIZED RECEIPTS AND EXPLANATION OF BENEFITS (if applicable) TO:
Blue Cross and Blue Shield of North Carolina
P.O. Box 35
Durham, NC 27702
FAX: 1-866-990-1385
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.
I certify that the information on this form is correct and the expenses incurred were necessary for the services filed.
Signature:
Date:
Daytime
Phone
Number:
® ®
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. All other trade names are the
property of their respective owners. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is an independent licensee of the Blue Cross and Blue Shield Association. BE236, 1/21
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Member Claim Form Requirements (BlueCross BlueShield of North Carolina)

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Completed 15 December 2021

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