Filing a Claim

Filing a Claim

 
When the Provider Files a Claim

The health care provider will file a claim for you when you receive a covered service from a covered provider who has a payment agreement with Blue Cross and Blue Shield. Or, for covered services you receive outside of Massachusetts, a health care provider will file a claim for you when he or she has a payment agreement with the local Blue Cross and/or Blue Shield Plan. Just tell the health care provider that you are a member and show the health care provider your ID card. Also, be sure to give the health care provider any other information that is needed to file your claim. You must properly inform your health care provider within 30 days after you receive the covered service. If you do not, coverage will not have to be provided. Blue Cross and Blue Shield will pay the health care provider directly for covered services when the provider has a payment agreement with Blue Cross and Blue Shield (or with the local Blue Cross and/or Blue Shield Plan).

When the Member Files a Claim

You may have to file your claim when you receive a covered service from a covered provider who does not have a payment agreement with Blue Cross and Blue Shield or a covered provider outside of Massachusetts who does not have a payment agreement with the local Blue Cross and/or Blue Shield Plan. The health care provider may ask you to pay the entire charge at the time of the visit or at a later time. It is up to you to pay your health care provider. To file a claim to Blue Cross and Blue Shield for repayment, you must:

  • Fill out a claim form;
  • Attach your original itemized bills; and
  • Mail the claim to the Blue Cross and Blue Shield customer service office.

You can get claim forms from the Blue Cross and Blue Shield customer service office. (See Part 1.) Blue Cross and Blue Shield will mail to you all forms that you will need within 15 days after receiving notice that you obtained some service or supply for which you may be paid.

When you receive covered services outside the United States, you must file your claim to the BlueCard Worldwide Service Center. (The BlueCard Worldwide International Claim Form you receive from Blue Cross and Blue Shield will include the address to mail your claim.) The service center will prepare your claim. This includes: converting your bill to U.S. currency; and sending it to Blue Cross and Blue Shield for repayment to you.

You must file a claim within two years of the date you received the covered service. This health plan will not have to provide coverage for services and/or supplies for which a claim is submitted after this two-year period.

Timeliness of Claim Payments

Within 30 calendar days after Blue Cross and Blue Shield receives a completed request for coverage or payment, Blue Cross and Blue Shield will make a decision. When appropriate, Blue Cross and Blue Shield will make a payment to the health care provider (or to you in certain situations) for your claim to the extent of your coverage in this health plan. Or, Blue Cross and Blue Shield will send you and/or the health care provider a notice in writing of why your claim is not being paid in full or in part.

Missing Information
If the request for coverage or payment is not complete or if Blue Cross and Blue Shield needs more information to make a final determination for your claim, Blue Cross and Blue Shield will ask for the information or records it needs. Blue Cross and Blue Shield will make this request within 30 calendar days of the date that Blue Cross and Blue Shield received the request for coverage or payment. This additional information must be provided to Blue Cross and Blue Shield within 45 calendar days of this request.

  • Missing Information Received Within 45 Days. If the additional information is provided to Blue Cross and Blue Shield within 45 calendar days of Blue Cross and Blue Shield’s request, Blue Cross and Blue Shield will make a decision within the time remaining in the original 30-day claim determination period. Or, Blue Cross and Blue Shield will make the decision within 15 calendar days of the date that the additional information is received by Blue Cross and Blue Shield, whichever is later.
  • Missing Information Not Received Within 45 Days. If the additional information is not provided to Blue Cross and Blue Shield within 45 calendar days of Blue Cross and Blue Shield’s request, the claim for coverage or payment will be denied by Blue Cross and Blue Shield. If the additional information is submitted to Blue Cross and Blue Shield after these 45 days, then it may be viewed by Blue Cross and Blue Shield as a new claim for coverage or payment. In this case, Blue Cross and Blue Shield will make a decision within 30 days as described previously in this section.