Blue cross blue shield out of network reimbursement form

Looking to find answers to your billing, claim forms, and other questions? Use our frequently asked questions to find answers.

Table of Contents Show

Where do I file a claim for medical care received outside the United States?
Whom do I contact when I have billing questions, get claim forms or talk to if a claim has been rejected?
How often is your BlueCard Doctor and Hospital Finder updated?
What is a Primary Care Physician (PCP)?
What is an HMO?
What is a PPO?
I was denied coverage, a claim, or received erroneous charged on my EOB, whom do I contact?
I am a member but I do not see where I can log in on this website. Where do I find access to my member benefits, coverage, etc?
How can I find out information about coverage that is supplemental to Medicare?
How can I get information on purchasing health insurance?
How do I submit a claim to BCBS Massachusetts?
How do I submit a claim to BCBS NC?
How do I file a Bcbstx claim?
How do I get my Florida Blue form 1095 A?

Where do I file a claim for medical care received outside the United States?

If you are eligible for the Federal Employee Program (your member ID starts with the letter R immediately followed by numbers), your overseas claim form and instructions can be found here.

If you are eligible for the Blue Cross Blue Shield Global Core program, enter the first three letters or numbers of your member ID here to access your international claim form and instructions.

Otherwise, contact your Blue Cross and Blue Shield company for assistance.

Whom do I contact when I have billing questions, get claim forms or talk to if a claim has been rejected?

How often is your BlueCard Doctor and Hospital Finder updated?

Each one of our Blue Cross and Blue Shield independent licensees (our member companies) collect and provide information for our PPO finder via different timetables and methods. While we make every effort to keep the Provider Finder "up-to-date," it is always best to confirm any provider information you select from this utility with your local Blue Cross and Blue Shield representatives.

What is a Primary Care Physician (PCP)?

A physician or other medical professional who serves as a group member's first contact with a company's health care system. Also known as a primary care provider, personal care physician or personal care provider.

What is an HMO?

HMO stands for Health Maintenance Organization, a health care system that assumes or shares both the financial risks and the delivery risks associated with providing comprehensive medical services to a voluntarily enrolled population in a particular geographic area, usually in return for a fixed, prepaid fee.

For more insurance terms and definitions, please see our Glossary.

What is a PPO?

A Preferred Provider Organization (PPO) is an arrangement designed to supply health care services at a discounted cost by providing incentives for members to use designated health providers (who contract with the PPO at a discount), but which also provides coverage for services rendered by health care providers who are not part of the PPO network.

I was denied coverage, a claim, or received erroneous charged on my EOB, whom do I contact?

To access specific information about your coverage and claims related to your individual or group health insurance, please contact the customer service number on the back of your member card. Otherwise, you can find your local BCBS company online. BCBS.com does not maintain member information.

I am a member but I do not see where I can log in on this website. Where do I find access to my member benefits, coverage, etc?

Bcbs.com is the Blue Cross and Blue Shield Association website. The Blue Cross and Blue Shield Association does not have access to member information. We regulate the brand and licenses to all 36 Blue Cross and Blue Shield local companies.

To access specific information about your coverage, EOBs, prescriptions, paying a bill, or any other questions related to your individual or group health insurance, please contact the customer service number on the back of your member card. You can also find your local BCBS company on BCBS.com.

How can I find out information about coverage that is supplemental to Medicare?

There are lots of Medicare choices, including Medicare+Choice, medical savings accounts and private fee-for-service plans. For plans available to you, use our Medicare guide. You can also view a listing of Blue Cross and Blue Shield companies who participate in Medicare Advantage and Prescription Drug choices. Contact your local BlueCross and Blue Shield representative for details regarding claims or coverage. Not sure which Blue company you belong to? You can find out by typing your home or work ZIP code in our Plan Finder.

How can I get information on purchasing health insurance?

The Blue Cross Blue Shield Association is an association of 35 independent, locally operated Blue Cross and/or Blue Shield companies.

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Fast Forms

Here you'll find the forms most requested by members. To download the form you need, follow the links below.

Can't view PDF documents? Download Adobe Acrobat®’ Reader.

Appeal and Grievance form [PDF]

Request an appeal if you feel we didn’t cover or pay enough for a service or drug you received.
Request a grievance if you have a complaint against Blue Cross or your health care provider.

Enhanced Dental Benefits Enrollment Form [PDF]
Your dental coverage policy must include Enhanced Dental Benefits in order to be eligible for coverage.

Blue Cross Blue Shield Global Core® Brochure [PDF]
An informational guide for Blue Cross members, traveling within the United States or abroad. BlueCard®’ and Blue Cross Blue Shield Global® Core ensure you have access to top doctors and hospitals and concierge-level service.

Open Enrollment Waiver Form [PDF]
If you did not purchase health insurance during open enrollment period, you may request a waiver, visit mass.gov.

Transition of Care for New Members [PDF]
Use this form if you want Blue Cross Blue Shield of Massachusetts to consider short-term coverage, at the in-network level of benefits, with your current out-of-network provider. This gives you some time to transition your care to an in-network provider.

Please note: This form does not apply to Medicare HMO Blue® or Federal Employee Plan (FEP) members.

Transition of Care/Continuity of Care Request Form [PDF]
This form can be used for a Blue Cross Blue Shield of Massachusetts member* who is:

- New to the plan and is receiving ongoing treatment from a provider that is not part of the Blue Cross network; or
- Receiving ongoing treatment from a provider that has recently left the Blue Cross network; or
- Using a tiered provider network and is receiving ongoing treatment from a provider that has moved to the highest cost-sharing tier.

*This form does not apply to Medicare HMO Blue® or Federal Employee Plan (FEP) members.

When you are billed for services from a provider that does not directly submit a claim to the local Blue Cross Blue Shield plan you may submit that claim for reimbursement.

To use our paper forms, download the appropriate form by clicking the links below and follow the instructions on the form.

Dental Claim Form [PDF]

A form for submitting a dental claim with instructions on filing a claim.

EyeMed Claim Form [PDF]

A form for submitting a vision claim for Medicare subscribers who have EyeMed as their routine vision benefits administrator.

Medical Claim Form [PDF]

A form for submitting a medical claim with instructions on filing a claim.

Medex®´ Subscriber Claim Form [PDF]

A form for submitting a claim for Medex subscribers with instructions on filing a claim.

Medicare Advantage Subscriber Claim Form [PDF]

A form for submitting a claim for Medicare Advantage subscribers with instructions on filing a claim.

Vision Claim Form [PDF]

A form for submitting a vision claim, with instructions for filing a claim.

COVID-19 At-Home Test Reimbursement form [PDF]

Eligible members can complete the COVID-19 At-home Test Reimbursement.

International claims form for care received outside of the U.S., Puerto Rico and the U.S. Virgin Islands.

International Claim Form [PDF]
A form for members submitting a medical claim when the care is received outside of the U.S., Puerto Rico, and the U.S. Virgin Islands.
*Medicare Advantage members please use Medicare Advantage Subscriber Claim Form above.

Reproductive Health Travel Benefit Reimbursement Form [PDF]

You may be eligible for reimbursement for certain travel expenses related to obtaining abortion services. To find out if you’re eligible, contact Member Services at 1-888-420-4501.

As a health care organization, we believe strongly that our members should have access to the care they need and want. To support our members in states where abortion access is legally restricted, we are reimbursing certain travel and lodging expenses related to abortion services (either surgical or medication-assisted). See our public statement.

Travel Benefit Reimbursement Form [PDF]

This benefit reimburses you for certain travel and lodging expenses related to obtaining covered services that are not available within 100 miles of your home. To find out if you’re eligible for this benefit, call Member Service at 1-888-420-4501.

Qualifying members will receive tax forms that serve as proof of health insurance coverage.

Form 1099-HC

We'll provide the 2020 Form 1099-HC to qualifying members who were enrolled in a Blue Cross Blue Shield of Massachusetts plan at any time during the calendar year. If you qualify, you'll receive your form:

Via mail, postmarked by January 31, 2021
On their MyBlue account, added on January 31, 2021

To see your Form 1099-HC from the last two years, sign in to MyBlue and, click My Inbox and then Documents. Or you can click directly from here. View My Tax Form.

04-1045815 is the Federal Tax ID (FID) for Blue Cross Blue Shield of Massachusetts for Health Care tax filing purposes.

You won't receive a Form 1095-HC if:

You're under 18 years old
You have a dental and/or vision-only plan through Blue Cross
You're enrolled in Medex®' or one of our Medicare Advantage plans

View Sample Form 1099-HC

If you haven't received your 1099-HC by the first week of February, 2021, please call Member Service at the number on the front of your ID card.

Form 1095-B

We'll provide the 2020 Form 1095-B to qualifying members who were enrolled in a Blue Cross Blue Shield of Massachusetts plan at any time during the calendar year. The form will be postmarked by January 31, 2021.

Your Form 1095-B states which months in 2020 you had health care coverage that meets the minimum essential coverage standards set by the federal government under the Affordable Care Act.

You won't receive a Form 1095-B if:

You're a member of a self-funded plan
You're a member with dental-only and/or vision-only plans through Blue Cross
You're enrolled in Medicare Part B or one of our Medicare Advantage plans
You're enrolled in a Health Savings Account plan
You're enrolled in wellness programs that are part of minimum essential coverage

If you haven't received your 1095-B by the first week of February, 2021, please call Member Service at the number on the front of your ID card.

Additional Tax Forms

In addition to Form 1099-HC and Form 1095-B, there are other health care-related tax forms that you won’t receive from Blue Cross. The deadline to provide these forms to qualified members is January 31.

Form 1095-A

Form 1095-A, or the Health Insurance Marketplace Statement, is for people who have health insurance through the Massachusetts Health Connector or an ACA Marketplace plan. This form will be provided to qualified members by their plan.

If you have a health plan through the Massachusetts Health Connector and haven’t received your Form 1095-A by January 31, visit Health Care Connector

Form 1095-C

Form 1095-C is for people who receive health insurance from their employer. This form will be provided to qualified members by their employer.

If you have employer-provided health insurance and haven’t received your Form 1095-C by January 31, please contact your employer or HR department.

How do I submit a claim to BCBS Massachusetts?

Call 1-800-200-4255(TTY: 711).

How do I submit a claim to BCBS NC?

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.

How do I file a Bcbstx claim?

Any claim that can be submitted on paper can be submitted electronically. If you need more information on how to submit claims electronically call 1-800-AVAILITY (282-4548) or log on to Availity .