Member forms

Most members can submit medical claims online in their Blue Connect℠ member services web portal. Members can also print forms and submit by mail or fax:

Medical, Vision, and Medical Supplies Claim Form (PDF)⁠

Formulario de reclamación para afiliados (Spanish) (PDF)⁠

• Mail: Blue Cross and Blue Shield of North Carolina
  PO Box 35
  Durham, NC 27702-3055
• Fax: 866-990-1385

Note: Use the member claim form if you needed health services on a cruise ship.

If you need to submit a prescription drug claim, you can choose the form you need below:

Prescription Drugs Claims Form (PDF)⁠

Formulario de reclamación por medicamentos recetados (Spanish) (PDF)⁠

• Mail: Prime Therapeutics (Commercial) Mail route BCBSNC
  PO Box 25136
  Lehigh Valley, PA 18002-5136

You may need these claim forms for services received or rendered outside of the US, For benefits received on a cruise ship, please submit the domestic claim forms.

International Claim Form (PDF)

• Mail: Service Center
  PO Box 2048
  Southeastern, PA 19399
• Email: claims@bcbsglobalcore.com
• Online: BCBS Global Core⁠

Reclamo Internacional (Spanish) (PDF)

• Mail: Bluecard Worldwide Service Center
  PO Box 261630
  Miami, FL 33126
• Email: claims@bluecardworldwide.com

You may need to submit a dental claim. You can choose the American Dental Association® (ADA) claim forms based on your type of Blue Cross NC dental plan below:

• ADA Blue Select Claim Form (PDF)
• ADA Claim Form for Individuals (PDF)
• ADA Pediatric Claim Form (PDF)
• ADA Claim Form for Dental Blue (PDF)
• Dental Claim Coordination of Benefits (PDF)

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.

Member Travel Benefit Form (PDF)

Member Travel Benefit Reimbursement for Transplant Services Form (PDF)

• Mail: Blue Cross and Blue Shield of North Carolina
  PO Box 35
  Durham, NC 27702-3055
• Fax: 866-990-1385

If you need to file a medical appeal, you can choose the form you need below:

Member Appeal Form (PDF)

Formulario de apelación de reclamaciones (Spanish) (PDF)

• Mail: Member Rights and Appeals
  Blue Cross and Blue Shield of North Carolina
  PO Box 30055
  Durham, NC 27702-3055

You can submit the Member Appeal Representation Authorization Form to choose and give a trusted representative the ability to file an appeal on your behalf. You can find the form and where to send it below:

Member Appeal Representation Authorization Form (PDF)

Formulario de autorización de representación ante apelaciones del afiliado (Spanish) (PDF)

• Mail: Member Rights and Appeals
  Blue Cross and Blue Shield of North Carolina
  PO Box 30055
  Durham, NC 27702-3055

If you need to file a dental appeal or grievance, you can choose the form you need below:

Dental Appeals and Grievances (PDF)

Dental Apelaciones y Quejas (Spanish) (PDF)

• Mail: Member Rights and Appeals
  Blue Cross and Blue Shield of North Carolina
  PO Box 2100
  Winston Salem, NC 27102-2100
• Fax: 336-714-0224

Allows members and their dependents to continue receiving care from a provider who is no longer in the Blue Cross and Blue Shield of North Carolina (Blue Cross NC) network.

Continuity of Care Form (PDF)

• Mail: Blue Cross and Blue Shield of North Carolina
  Care Management
  PO Box 2291
  Durham, NC 27702-2291
• Fax: 800-228-0838

You have the right to give a caregiver, loved one, or trusted person access to your protected health information (PHI). In order to do so, you need to give Blue Cross NC written authorization.

Parents or guardians of dependent children over 18 (or between the ages of 14–18 for certain diagnoses) will also need their dependent to provide authorization before we can share their PHI with you.

You can submit online through your Blue Connect member portal. 

You can also print, complete, and mail or fax the form.

Authorization Request Form (PDF)

Authorization Request Form (Spanish) (PDF)

• Mail: Commercial Operations / IDC
  Blue Cross and Blue Shield of North Carolina
  PO Box 2291
  Durham, NC 27702-2291
• Fax: 800-228-0838

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.

Student Leave of Absence Certification Form (PDF)

• Mail: Blue Cross and Blue Shield of North Carolina
  Manager Enrollment and Billing Operations
  PO Box 2291
  Durham, NC 27702-2291

You can request a certificate for terminated (ended) policies from Blue Cross NC for up to 24 months following termination. If your policy is still active, and you need a Certificate of Creditable Coverage document, please call the Customer Service number on your Blue Cross NC member ID card.

To submit an online request or change, you must be a member of the reference Blue Cross NC health plan, or a group benefits administrator authorized to make requests or changes on the member's behalf. Following receipt of your request, you will receive your proof of coverage certificate through regular mail within 10 days.

If you would still like a copy of Form 1095-B, you can get a copy from Blue Connect.

Don't have an account yet? Register for Blue Connect now.

Call us to request a copy:  800-326-0052

Request a copy via email: TaxFormRequest@bcbsnc.com

Please be aware that e-mail communication can be intercepted in transmission or misdirected. If you are uncomfortable with sending your health information via unsecured email, please consider communicating by using one of the other methods on this page.

Please include the following information in your email to us:

1. Name (as it appears on your member ID card)
2. Email address
3. Member ID
4. Date of birth
5. Home mailing address

By sending an email to this address, I am affirmatively consenting to receive my 1095-B Form via email and understand by doing so that I will not receive a paper copy of Form 1095-B unless I specifically request one. As a convenience to me, I hereby request and authorize Blue Cross and Blue Shield of North Carolina (Blue Cross NC) to provide me with this form electronically. I understand that it is my responsibility to ensure Blue Cross NC has my up-to-date email address and that it is in fact correct and accurate. I further understand that I am solely responsible for ensuring my email address is functioning properly at all times and that Blue Cross NC has no liability for errors in transmission of the electronic Form 1095-B other than addressing the electronic form to the email address I provided. I acknowledge and agree that the date of receipt of my electronic Form 1095-B shall be the date and time on which I requested it, regardless of the date and time I actually receive and/or review this form.

Send a request in writing to Customer Service:

Blue Cross NC
ATTN: IRC6055
PO Box 2291
Durham, NC 27702