Check the back of your Blue Cross ID card to determine which plan you have. Type or use blue or black ink to complete. You can also call 1-800-624-5060 for more information, claim forms and customer service assistance. ... BlueCross BlueShield of South Carolina Consumer Products, AF-525 P.O. For vision reimbursement claims, Heritage and VSP have their own claim forms and processes. Learn more about filing a complaint or appeal. Dental. Download the forms you need to efficiently administer your ancillary products. When submitting claim appeal letters, please attach supporting documentation (chart notes, x-ray reports, etc.). Box 805107 Chicago, IL 60680-4112. Life, Disability, Accident, Critical Illness, Vision and Dental Enrollment and Change Form – You may use this form to enroll in any or all of our group ancillary products. Attach an original itemized bill from … If you have a complaint about a claim, start by calling customer service at the number on the back of your member ID card. 3. 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. The Request for Professional Claim Adjustment form should be used for services submitted on a CMS-1500. Members can mail the completed claim to: OR. Do not file prescription drugs on this form. Member Claim Form. Instructions for Submitting Claims 1. Member Forms. Outside the United States. Prescription Claim Form Prescription Exception Request Form ... ©1998-2020 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. Member claim submissions can also be made via secured message in the Message Center by logging into Blue Access for Members SM. What you'll need: Your Blue Cross ID card; Original receipts from your doctor, pharmacy, etc. If the information being submitted was requested by Blue Cross Blue Shield of WY, please attach a copy of the request. Select Blue Cross Blue Shield Global™ or GeoBlue if you have international coverage and need to find care outside the United States. Submit a claim only when you are billed for services from a provider that does not directly submit a claim to the local Blue Cross Blue Shield plan. Members can also fax claims to: Blue Cross and Blue Shield of Alabama Claims Department Post Office Box 995 Birmingham, Alabama 35298-0001. Box 52057, Phoenix, AZ 85072-2057. ; Evidence of Insurability – Medical Evidence of Insurability for coverage changes. You’ll need to use separate forms for dental claims, prescription drug claims and contraceptive prescriptions or services claims. Submit a separate form for each patient. 2. 205-220-2146. The claim form provides detailed instructions for submission of the form and should be mailed to: Service Benefit Plan Retail Pharmacy Program, P.O. In the United States, Puerto Rico and U.S. Virgin Islands. BlueCross BlueShield of Tennessee is a Qualified Health Plan issuer in the Health Insurance Marketplace. Browse commonly requested forms to find and download the one you need for various topics including pharmacy, enrollment, claims and more. Box 100133 Columbia, SC 29202-3133. Use these forms to file claims for medical services: Health Benefits Claim Form State Health Plan Comprehensive Benefits Claim Form. Prescription Claims. 800-526-8529 Blue Cross NC is Downloadable Forms. Unless otherwise noted on the form, please send completed forms with any required documentation to: Blue Cross and Blue Shield of Illinois P.O. Search for Doctors, Hospitals and Dentists Blue Cross Blue Shield members can search for doctors, hospitals and dentists:. 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