How to submit a claim

You might need to submit a claim when you:

• Visit an out-of-network provider
• Receive medical services in another country (use the international claim form) or while on a cruise ship (use the member claim form)
• You’re being reimbursed for vision or prescription products or services1

You might not need to submit a claim when you:

• Visit a North Carolina hospital for services or emergency care. If they have your insurance information, they'll file your claim for you.
• Use an in-network doctor. Need help finding an in-network provider? Try our Find Care tool.

To avoid delays and have your claims processed accurately, be sure you submit all of the following:2

1. A claim form - signed and completed for each member or patient who received care.
2. A receipt -  Your doctor will give you an itemized receipt for all the services you received. You should submit the original (not a copy) with your claim.
3. Valid procedure codes -  For example, 99203 is the code for an office or outpatient visit for evaluation. Get these codes from your doctor.
   • Get a different procedure code for each service, and
   • Get a separate charge for each procedure code                  
4. A diagnosis code for services or supplies. Get these codes from your doctor.

Did you visit an out-of-state provider?

You should also provide this information from the referring provider and the provider you saw:

1. Name and address
2. NPI
3. Tax ID number

Medical, vision and medical supplies claims forms

• Member claim form (PDF)
• Requisitos del formulario de reclamación para afiliados (Spanish) (PDF)

Prescription drug claims forms

• Prescription claim form (PDF)
• Formulario de reclamación por medicamentos recetados (Spanish) (PDF)

Claim forms for services rendered outside of NC

• International claim form (PDF)
• Reclamo Internacional (Spanish) (PDF)