Claim Information for Members

Sometimes, members are required to submit claims for medical services they receive or for reimbursement. 

You must submit a claim form when:

• You visit an out-of-network (OON) doctor, provider, or specialist
• You receive medical services in another country or while on a cruise ship (for cruise ships, use the general Member Claim Form)
• You're being reimbursed for vision or prescription products or services¹

Note: All North Carolina hospitals contract with Blue Cross NC. That means they file your claim for you. Just give them your Subscriber ID number when you visit for services or emergency care.

Steps to Submit a Claim Form:

1. Complete, sign and submit a separate claim for each member or patient that received care.
2. Submit original itemized receipts with your claim.
   • Your doctor will give you an itemized receipt for all the services you received. 
3. Make sure you receive a valid procedure code for each service. You can get these from your doctor.
   • For example: Code 99203 is the code for an office or outpatient visit for evaluation. 
4. Submit a separate charge for each procedure code.
5. Provide a diagnosis code for services or supplies. You can get these codes from your doctor.

Things to Remember:

• Submit and file a Blue Card international claims form for services received outside the U.S. You can mail the form to the address at the top of the claim form.
• Make sure you are filing with the plan (i.e. Blue Cross NC) that holds the member’s policy.
• Complete and sign the Prime Claim form for prescriptions and send it to the address on the back of the form.
• For out-of-state providers, please provide the name, NPI, Tax ID number, and address for:
  • Rendering provider
  • Referring provider