Filing a Medical Claim for Services Received in the United States

Follow the steps below to file a claim from a non-network provider for services received in the U.S.

To avoid a delay in the processing of your claim, be sure you have a recent Coordination of Benefits form on file with the Health Plan before submitting your claims to Blue Cross.

Step 1: Download the Claim Form – Medical – Services Received in the U.S.

NOTE: For fastest processing, you must include both a completed claim form AND your itemized bill. In lieu of the claim form, an itemized bill may be accepted alone as long as it includes BOTH (1) the information normally supplied on the claim form and (2) the required information for the itemized bill (detailed in Step 2).

Step 2: Complete your claim form in its entirety and attach your itemized bill.

Your itemized bill must include the following:

• Name and address of provider
• Place of service (doctor, hospital, laboratory, ambulance service, etc.)
• Name of patient
• Service provided
• Date of service
• Amount charged for each service
• Diagnosis code
• Procedure code
• Tax ID

Step 3: Submit your claim.