Claims Information for non-U.S. Participants

Submitting a Medical Claim

To submit a medical claim for services received outside the U.S., follow the three steps below.

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

This is the BlueCross BlueShield Global Core International Claim Form. You should submit the completed form along with any itemized bill you might have.

Step 2: Be sure your completed claim (which includes a completed BlueCross BlueShield Global Core International Claim Form with or without an itemized bill) includes all the information below. If you do not provide all of the required information, your claim could be delayed.

• Health Plan Participant’s Information
  • Name
  • Health Plan ID Number (as it appears on your Health Plan ID Card)
  • Health Plan Group Number
• Patient’s Information
  • Name
  • Date of Birth
• Provider’s Information
  • Name
  • Address
  • Federal Tax ID Number
• Service Information
  • A Description of Services and Diagnosis (provided by the doctor).
  • Amount Paid (if any)

Step 3: Submit your claim to BlueCross BlueShield Global Core using the information below.

It is recommended that you submit your claim by email, mobile app or online in order to have proof of your claim submission.

If you have any questions regarding your medical claim, you can reach BlueCross BlueShield Global Core at (804) 673-1177.

Submitting a Prescription Claim

To be eligible for coverage under the Health Plan’s prescription drug benefit, a medication must be available in the United States and have received FDA approval. If you are unsure if the medication is FDA-approved, you can call the Health Plan Office at (323) 866-2200, Ext. 401.

Step 1: Fill out the Prescription Drug Claims Form.

• In the Group /Group Name field, write in the RxGRP from your CVS Caremark prescription card.
• In the Identification Number field, write in the ID that appears on your CVS Caremark prescription card.

Step 2: Be sure to include prescription receipts with your claim form.

Step 3: Mail the completed form and additional information to:

Submitting a Dental Claim

All foreign dental claims should be filed with Delta Dental, the Health Plan’s dental benefit manager.

Step 1: Fill out the Dental Plan Claims Form. Complete sections 1-15 of the form.

• For Section 9, Employer (Company) Name, write in “DGA-PPHP.”
• For Section 10, Group Number, write in “0480.”

If you do not have a U.S. social security number, you can either call our office for the alternate social security number we assigned to you for identification purposes or enter your “Enrollee Number” which appears on your Delta Dental coverage card.

Step 2: Attach a copy of the dentist’s statement of treatment to the claim form. The statement of treatment should include the dentist’s name, phone number, a description of each service the dentist performed, and the amounts billed and paid for each service.

Step 3: Mail the completed form and statement to:

Delta Dental
P.O. Box 997330
Sacramento, CA 95899-7330

If you have any questions regarding your claim, call Delta Dental at (415) 972-8300.

Submitting a Vision Claim

All foreign vision claims should be filed with Vision Service Plan, the Health Plan’s vision benefit manager.

Step 1: Fill out the VSP Out of Network Reimbursement Form.

Step 2: Submit the completed form and itemized receipts.