Claims

In most instances you do not have to file claims. The participating provider will file claims for you. However, you will need to file claims for any lenses, frames and dental products or services received.

If you need a claim form or help on how to file a claim, call Blue Cross NC's Customer Service at 1-877-258-3334 or write to:

Blue Cross NC Customer Service
P. O. Box 2291
Durham, NC 27702-2291

Please mail your dental claims to:

Blue Cross Blue Shield of North Carolina
Attn: Dental Blue Claims Unit
PO Box 2100
Winston-Salem, NC 27102

Blue Cross Blue Shield of North Carolina
Attn: Dental Blue Select Claims Unit
PO Box 2400
Winston-Salem, NC 27102

If your member ID card says Prime Therapeutics on back, your prescription benefits are administered through Prime Therapeutics. Complete a claim form to file a claim for prescription drug benefits obtained at a non-participating pharmacy. Claim forms should be mailed to:

PrimeMail
PO Box 650041
Dallas, TX 75265-0041

If your member ID card says Medco on the back, your prescription benefits are administered through Medco, Inc. To file a claim for prescription drug benefits obtained at a non-participating pharmacy, you may download the form online. Prescription drug claims should be sent to:

Medco Health Solutions, Inc.
P.O. Box 14711
Lexington, KY 40512

(In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately. Please refer to your Member Guide to confirm that your pharmacy benefits are offered through Blue Cross NC.)

If you need to submit a claim, please mail it in time to be received by Blue Cross NC within 18 months after the service was provided. Claims not received within 18 months from the date the service was provided will not be covered, except in the absence of legal capacity of the member.

Participating providers may only bill you for non-covered services or collect any applicable deductible, copayment or coinsurance amounts. Non-participating providers may bill you for the difference in what Blue Cross NC allows and their actual charge. You will receive an Explanation of Benefits (EOB) report from Blue Cross NC in the mail after you receive services. This EOB should outline the amount you owe. If you need assistance with provider bills, please contact Customer Service at 1-877-258-3334.

You can check the status of a claim by logging on to Blue Connect . With Blue Connect, you can access the following information regarding a submitted claim:

• Processing status
• Date received
• Billing and payment amounts
• How much money has been applied toward deductible
• Coverage ratios for any member covered on the policy

A deductible is the dollar amount you must pay for covered services in a benefit period before benefits are payable by Blue Cross NC. You must satisfy your deductible amount once each benefit period. The deductible does not apply to most services where a copayment applies, with the exception of emergency room visits or in-patient stays. In those cases, the copayment is couple with the applicable deductible.

A copayment is the fixed dollar amount you must pay for some covered services. The provider usually collects this amount at the time the service is provided. Copayments are not credited toward the individual or family benefit period deductible.

Coinsurance maximum is the total amount of coinsurance that a member is obligated to pay for covered services per benefit period. This amount excludes any deductibles, copayments, and non-covered services.

If you are enrolled in both a Blue Cross NC health plan and another group health plan, we may coordinate benefits with the other plan.

Coordination of Benefits (COB) means that if you are covered by more than one insurance plan, benefits under one plan are determined and paid before the second plan's benefits are determined and paid. The plan that determines benefits first is called the primary plan. The other plan is called the secondary plan. COB is explained in more detail in your Member Guide.

From time to time you may receive a Coordination of Benefits questionnaire from Blue Cross NC so that we know to coordinate benefits with the other benefit plan. The advantage of having two benefit plans is that a greater portion of your out-of-pocket expenses may be covered by the secondary plan. Even if you do not have two benefit plans, returning the questionnaire will help us keep our records accurate.

Answers vary according to plan. For more information, please visit the FAQs on your plan's member page.