For Individuals and Families Under Age 65
Blue Cross NC members can file a claim, appeal a denial of benefits, and learn more about their coverage depending on their type of plan.
Don't see what you need? Log in to Blue Connect or call the customer service number on the back or your member ID card.
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.
Formulario de reclamación para afiliados (Spanish)
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.
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.
Claims for services received outside NC:
Claims for benefits received outside the U.S.
For benefits received on a cruise ship while outside the country; please submit the domestic claim forms.
Formulario de apelación de reclamaciones (Spanish)
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:
About Interactive PDFs: You can add your information directly on the form to complete it, however, completed forms cannot be saved. You can save a blank version of the form. We recommend printing a copy for Blue Cross NC and one for your records. To view PDF documents you need Adobe Acrobat Reader, provided free from Adobe.com.
Forms and resources for Blue Medicare HMO, Blue Medicare PPO, and Blue Medicare Rx (PDP) Members.
Dental Claims Forms
Appeals and Grievances
Apelaciones y quejas (Spanish)
Blue 20/20 Vision Benefit Booklets*
*Information provided for employer group members