Manage Claims & Records

If you use a provider outside of our network, you'll need to complete and file a claim form to be reimbursed. Use this form to submit a health benefit claim for services that are covered under the Blue Cross and Blue Shield Service Benefit Plan. Submit a separate claim for each patient.

• Download the health benefits claim form

   

    English   Español
• Complete the form following the instructions on the back. (You can fill the form in electronically or complete it by hand.)
• Include itemized bills for covered services or supplies.
• Print and mail the form to the Blue Cross and Blue Shield company in the state that the services were rendered by December 31 of the year following the year you received service. Find your local company's address.

Use this form to submit a claim to be reimbursed for services that are covered under Service Benefit Plan dental benefits. Submit a separate claim for each patient.

• Download the dental claim form:

            English

• Complete the form following the instructions on the back. (You can fill the form in electronically or complete it by hand.)
• Print and mail the form to your local Blue Cross and Blue Shield company by December 31 of the year following the year you received service. Find your local company’s address.

Use this form to submit a claim to be reimbursed for paying Medicare Part B premiums. Submit a separate claim for each member.

• Download the Medicare Reimbursement Account (MRA) Pay Me Back claim form:
    English

 

• Complete the form following the instructions on the front. (You can fill the form in electronically or complete it by hand.)
• Include proof that you paid a Medicare Part B premium. Make sure your documents include the five following pieces of information as required by the IRS:


• Date of payment
• Provider name (which is Medicare in this case)
• Detailed description
• Proof of payment
• Name


• You can fax the form, along with proof that you paid a Medicare Part B premium, to 877-353-9236.
• You can upload the form through the EZ Receipts mobile app, available at the App Store^® and Google Play^™.
• You can upload the form through the online portal.
• Or mail a paper copy, along with proof that you paid a Medicare Part B premium, to:

Claims Administrator
P.O. Box 14053
Lexington, KY 40512

Overseas members must file claim forms for any covered medical or pharmacy services received outside of the United States. Submit a separate claim for each patient.

Submitting your overseas medical and prescription drug claims online is easy and provides faster processing and claims payment. 

You can submit them through MyBlue, our secure members-only website. Use MyBlue to access your personal health information wherever you go. 

If you use a provider outside of our network, you'll need to complete and file a claim form to be reimbursed. Use this form to submit a health benefit claim for services that are covered under the Blue Cross and Blue Shield Service Benefit Plan. Submit a separate claim for each patient.

• Download the FEP Medicare Prescription Drug Program claim form

  English

• Complete the form following the instructions on the back. (You can complete it electronically or by hand.)
• Include itemized bills for covered services or supplies.
• Print and mail the form to the Blue Cross and Blue Shield company in the state where you received services by December 31 of the next calendar year. Find your local company's address.