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Frequently Asked Questions

Claims


Q: How do I file a claim?  Top of Page

A: In most instances you do not have to file claims. The participating provider will file claims for you. However, you will need to file claims for any lenses, frames and dental products or services received.

If you need a claim form or help on how to file a claim, call BCBSNC's Customer Service at 1-877-258-3334 or write to:

BCBSNC Customer Service
P. O. Box 2291
Durham, NC 27702-2291

Please mail your dental claims to:

Blue Cross Blue Shield of North Carolina
Attn: Dental Blue Claims Unit
PO Box 2100
Winston-Salem, NC 27102

Blue Cross Blue Shield of North Carolina
Attn: Dental Blue Select Claims Unit
PO Box 2400
Winston-Salem, NC 27102

If your member ID card says Prime Therapeutics on back, your prescription benefits are administered through Prime Therapeutics. Complete a claim form to file a claim for prescription drug benefits obtained at a non-participating pharmacy. Claim forms should be mailed to:

PrimeMail
PO Box 650041
Dallas, TX 75265-0041

If your member ID card says Medco on the back, your prescription benefits are administered through Medco, Inc. To file a claim for prescription drug benefits obtained at a non-participating pharmacy, you may download the form online. Prescription drug claims should be sent to:

Medco Health Solutions, Inc.
P.O. Box 14711
Lexington, KY 40512

(In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately. Please refer to your Member Guide to confirm that your pharmacy benefits are offered through BCBSNC.)

Q: How long do I have to file a claim? Top of Page

A: If you need to submit a claim, please mail it in time to be received by BCBSNC within 18 months after the service was provided. Claims not received within 18 months from the date the service was provided will not be covered, except in the absence of legal capacity of the member.

Q: A provider has billed me; how do I know how much of the bill to pay? Top of Page

A: Participating providers may only bill you for non-covered services or collect any applicable deductible, copayment or coinsurance amounts. Non-participating providers may bill you for the difference in what BCBSNC allows and their actual charge. You will receive an Explanation of Benefits (EOB) report from BCBSNC in the mail after you receive services. This EOB should outline the amount you owe. If you need assistance with provider bills, please contact Customer Service at 1-877-258-3334.

Q: How can I check the status of my claim? Top of Page

A: You can check the status of a claim by logging on to My Member Services at bcbsnc.com. With My Member Services, you can access the following information regarding a submitted claim:

  • Processing status
  • Date received
  • Billing and payment amounts
  • How much money has been applied toward deductible
  • Coverage ratios for any member covered on the policy

Q: What is the difference between deductibles and copayments? Top of Page

A: A deductible is the dollar amount you must pay for covered services in a benefit period before benefits are payable by BCBSNC. You must satisfy your deductible amount once each benefit period. The deductible does not apply to most services where a copayment applies, with the exception of emergency room visits or in-patient stays. In those cases, the copayment is couple with the applicable deductible.

A copayment is the fixed dollar amount you must pay for some covered services. The provider usually collects this amount at the time the service is provided. Copayments are not credited toward the individual or family benefit period deductible.

Q: How does my coinsurance maximum work? Top of Page

A:Coinsurance maximum is the total amount of coinsurance that a member is obligated to pay for covered services per benefit period. This amount excludes any deductibles, copayments, and non-covered services.

Q: What is Coordination of Benefits (COB)? Top of Page

A: If you are enrolled in both a BCBSNC health plan and another group health plan, we may coordinate benefits with the other plan.

Coordination of Benefits (COB) means that if you are covered by more than one insurance plan, benefits under one plan are determined and paid before the second plan's benefits are determined and paid. The plan that determines benefits first is called the primary plan. The other plan is called the secondary plan. COB is explained in more detail in your Member Guide.

Q: Why did I receive a Coordination of Benefits (COB) questionnaire and do I have to return it? Top of Page

A: From time to time you may receive a Coordination of Benefits questionnaire from BCBSNC so that we know to coordinate benefits with the other benefit plan. The advantage of having two benefit plans is that a greater portion of your out-of-pocket expenses may be covered by the secondary plan. Even if you do not have two benefit plans, returning the questionnaire will help us keep our records accurate.

Q: What do I do with a foreign medical bill for care I received outside of the U.S.? Top of Page

A: Answers vary according to plan. For more information, please visit the FAQs on your plan's Member page.