CLAIMS &
STATEMENTS

How to Submit a Claim

Need to submit a claim? Download and complete the appropriate form below, then submit it by December 31 of the year following the year that you received service. (For example, if your service was provided on March 5, 2018, you have until December 31, 2019 to submit your claim). Keep in mind that you must first pay your provider directly for all services and then submit your claim to us for reimbursement. If you have questions, please contact your local Blue Cross and Blue Shield company.

  • Health Benefit Claims-

    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: 

      pdf document English   pdf document 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.
    • Dental Claims-

      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: 

        pdf document 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.
      • Medicare Reimbursement Account Claims-

        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 Medicare Reimbursement Account (MRA) Pay Me Back claim form: 

          pdf document 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.
        • 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.
        • Or mail a paper copy, along with proof that you paid a Medicare Part B premium, to:
        • Mail the completed form to:

          Claims Administrator
          P.O. Box 14053
          Lexington, KY 40512
        • Overseas Claims-

          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.

          Medical Claims

          • Download the overseas medical claim form:

            pdf document  English

          • Complete the form following the instructions on the back.
          • Include itemized bills for covered services or supplies.
          • You can submit this form and upload images of your itemized bills online, or mail a paper copy, along with your itemized bills, to: 

            Federal Employee Program (FEP) Overseas Claims
            PO Box 260070
            Pembroke Pines, FL 33026

          Pharmacy Claims

          • Download the overseas retail prescription drug claim form:

            pdf document  English
                pdf document Español 

          • Print and complete the form according to instructions on the front.
          • Attach pharmacy receipts for covered prescriptions.
          • You can submit this form and upload images of your receipts online, or mail the form, along with your receipts, to: 

            Service Benefit Plan
            Retail Pharmacy Program
            P.O. Box 52057
            Phoenix, AZ 85072-2057
          • FEP BlueVision Direct Reimbursement Claims-

            FEP BlueVision is supplemental coverage that you can purchase for an additional fee. It is not a part of the Blue Cross and Blue Shield Service Benefit Plan.

            Use this form to submit an out-of-network claim, along with copies of the provider’s bills. Submit a separate claim for each patient.

            • Download the FEP BlueVision claim form:

              pdf document  English 

            • Print and complete the form following the instructions.
            • Ask your provider to sign your form.
            • Mail the completed form to:

              FEP BlueVision
              P.O. Box 2010
              Latham, NY 12110-2010

            Explanation of Benefits (EOBs)

            An EOB is an outline of what services you received from a provider and how your benefits were applied to cover those services. You can view your personal EOBs through your MyBlue account.

            Learn More

            Get more with MyBlue®

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