Claim Procedures

Claims incurred from services performed by a participating provider (who participates in a Blue Cross Blue Shield managed care network or accepts Blue Cross Blue Shield UCR) will be the responsibility of the provider to file. Claims incurred from services performed by a non-participating provider will be the responsibility of the subscriber (employee and/or dependents) to file. In addition, there may be a time after enrolling in a program and prior to receiving your cards in which you may have to file a claim yourself.

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Step 1 - Identify the Claim Form required

Use the table above to determine which claim form you need to submit. Once you find the form you need, you can download it, print it and submit it via regular mail or fax, depending on the instructions on the form. To obtain a claim form by email, please click here.

If you require a form currently not available online, or if you are unable to download a form, contact the Council's Employee Benefits Group to have the appropriate form delivered to you via regular mail or electronic mail.

Step 2 - Complete a claim form

Make sure that all the information is properly completed, signed and dated by the subscriber or the benefits administrator.

Step 3 - Obtain an itemized bill

Obtain an itemized billing statement from the provider listing the following information:

• Name and address for the provider (doctor, hospital, etc.)
• Patient's full name
• Dates of service
• Description of the services performed on each date or description of the item
• Amount charged for each service or item
• Diagnosis or nature of illness
• Doctor's certification (durable medical equipment)
• Nurse's license number and shift worked (private duty nursing)
• To, from, and total mileage (ambulance services)
• Day's supply (prescription drugs)

Step 4 - Mail the claim form

After steps 1 and 2 have been completed, attach all itemized bills to the claim form and mail to the address listed at the top of the form. If the subscriber has already made payment for services received, proof of payment must also be submitted with the claim.

Once submitted, claim forms and bills cannot be returned. Subscribers should retain for their records copies of all items submitted.

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Medical Claim Forms

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Prescription Claim Forms

¹Subscribers enrolled in a managed care plan will only have to file a prescription drug claim form if they have not yet received or have lost their ID card, otherwise all prescription drug claims will be filed by the pharmacist.

²The prescription drug program for the traditional plan includes an acute drug and a maintenance drug benefit. All acute drugs must be filed towards the subscriber’s deductible using the appropriate medical claim form. A subscriber will only have to file a prescription drug claim form for maintenance medications if they have not yet received, or have lost their ID card.

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Dental and Vision Claim Forms

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Once a claim has been processed, the subscriber will receive an Explanation of Benefits (EOB). The following information is detailed on the EOB:

• Actual charges
• Allowed charges
• Deductible and coinsurance amounts, if any, the subscriber is required to pay
• Total benefits payable
• Subscriber responsibility (how much they owe)

If an amount is denied, an explanation will be listed on the EOB. Occasionally the EOB will request additional information needed to process the claim. If such information is not furnished, the claim will not be finalized.

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Use the table below to determine who you should call to determine the status of your claim; please have your group and identification numbers ready.

Claim Type	Program(s)	Contact
Medical, Prescription	All Plan Designs	Dedicated Customer Service Unit: (800) 325-4560
Short Term Disability	Please Contact: Hartford Life Insurance Co. 1 800 523-2233
Long Term Disability
Dental	Dental Options I-IV	Customer Service: (800) 332-0366
Vision	OptiChoice	Customer Service: (800) 541-2039
	Vision Benefits of America	Customer Service: (800) 432-4966

If you have any further questions, please contact us; we'll be glad to help you.

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This information is not intended for use without professional advice. While we have attempted to make this site as accurate as possible, it is only a summary. For more information, see our disclaimer.

Last updated on:  Thursday, December 22, 2005  Page: 

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