Have you received services from an out-of-network provider? Need to file for medical services or supplies, such as glasses or contact lenses? Out-of-network providers and some medical supplies or services require you to file a claim form.*

Download our interactive forms for medical, vision and medical supplies claims. Instructions are included on each form. You can enter your information directly in the form, print it and mail it to us. A few things to know as you use the forms:

• When you click the print button on the form, a message will appear if required information is missing.
• Move your mouse over the text fields -- there you'll find helpful information about completing the form.
• If you save the form to your computer, any text you entered in the form will not be saved.

* If you receive services from a provider participating in the BCBSNC network, the provider will file your claim but we recommend you confirm this with your provider or use our Find a doctor search before filing a claim.

If you received dental services (and have BCBSNC dental coverage), please verify with your provider whether you should file a claim for reimbursement. Claim forms are available below to download and submit. In the event of a denied claim, certification, or authorization of a service, you can submit an appeal within 180 days of the denial.

Dental Blue – Individual plan
Dental Blue – Group plan
Dental Blue Select – Group Voluntary plan

In the event of a denied claim, certification, or authorization of a service, you can submit an appeal within 180 days of the denial. To learn more about our appeals process and to complete our other coverage details form (if you are covered under another health plan), please log in to Member Services.

If you need to appeal a denied claim, call Customer Service at the number given on the back of your ID card to see if your concern can be resolved over the phone. If an appeal is still required, you will need to download and complete the Claim Appeal Form.

Claim Appeal Form

BCBSNC will not share your protected health information unless we have legal permission to do so. If you rely on your spouse, family member or close friend to assist with your claims or payment information, we cannot release information to them without signed authorization from you.

BCBSNC Member Authorization Form

If you received medical services while outside the country, you may download and submit the claim forms below for reimbursement.

 International Claim Form (English)
 Reclamo Internacional (Spanish)
 Sample complete claim form
 Prescription Drug Claim Form
 Dental Blue Group Claim Form

If your coverage with BCBSNC has ended and you need a Certification of Health Insurance Coverage to verify the effective dates of your coverage, you can order it here. If your coverage is still active and you need a Certification of Health Insurance Coverage, please call the Customer Service number on your BCBSNC ID card.
Order Certification of Health Insurance Coverage

As a Blue Cross and Blue Shield of North Carolina (BCBSNC) member, you have certain rights and responsibilities. Download the PDF below.

Member Rights and Responsibilities

If your dependent child loses their student status at a college, university or other postsecondary educational institution due to a leave of absence caused by a serious illness or injury, you may be able to continue their coverage.

Have your physician complete the following form to certify your dependent child's medically necessary leave of absence.

Student Leave of Absence Certification Form