Member Booklets, Forms & Documents

Claims for Benefits Received in North Carolina or Out-of-Network in the U.S. 
Note: most providers in the Blue Cross NC network will file a claim on your behalf.

• Medical, Vision and Medical Supplies

• Formulario de reclamación para afiliados (Spanish)

• Prescription Drugs

• Formulario de reclamación por medicamentos recetados (Spanish)

Claims for OTC COVID-19 Tests 
Note: the below claim form should be completed for OTC COVID-19 tests. A pharmacist signature and pharmacist NPI number are NOT required on the claim form.  However, the member MUST sign the form attesting that the test kits are not being used for testing required by their employer, return to work, travel, attending recreational events, and will not be resold.

• OTC COVID-19 test claim form

Claims for Travel Benefits 
The claim form only applies if your health plan offers a travel benefit. You must sign the form to verify that you traveled out of state for a medical service covered and approved by your health plan. Check your Benefit Booklet or contact your Plan Administrator to learn more.

• Member Travel Benefit Claim Form

Claims for services received outside NC:

• BlueCard

Claims for benefits received outside the U.S.

• International Claim Form  

• Reclamo Internacional (Spanish)

For benefits received on a cruise ship while outside the country; please submit the domestic claim forms.

• Member Appeal Form

• Formulario de apelación de reclamaciones (Spanish)

• Member Appeal Representation Authorization Form

• Formulario de autorización de representación ante apelaciones del afiliado (Spanish)

These appeals forms are unintended for appealing underwriting decisions. If you wish to appeal an underwriting decision, try one of the following:

• Check your underwriting decision letter for appeal instructions.
• Contact your local agent.
• Call us at 1-888-922-3140.

• Continuity of Care Form – allows members and their dependents to continue receiving care from a provider who is no longer in the Blue Cross NC network.

• Order Certification of Health Insurance Coverage – for terminated (ended) policies

• Blue Cross NC Member Authorization Form – authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose.

• Student Leave of Absence Certification Form – certifies a dependent child has lost their student status at a postsecondary educational institution due to a leave of absence caused by a serious illness or injury. You may be able to continue their coverage. A physician must complete this form.

• Solicitud de autorización del afiliado (Spanish)

Members log in to Blue Connect for more information:

• Member Appeals

• Provide Details of Other Coverage