Coordination of Benefits Form

Who is this for?

If you are a Blue Cross Blue Shield of Michigan or Blue Care Network member, use this form to tell us whether you have other health insurance besides ours.

We use this form to ask you whether you, your spouse or any of your covered dependents have health insurance through another company.

If you have additional coverage from another health insurance company, we can work with them to coordinate your benefits and make sure your claims are paid with the least amount of hassle to you. Before completing the form you will need to gather the following documents:

If you don't have additional coverage, you still need to fill out the form.

Complete your Coordination of Benefits form online

Log in to your bcbsm.com account and you'll be guided through the form.

If you are a Blue Cross Blue Shield of Michigan member (PPO/traditional), only the subscriber can fill out the form. If you are a Blue Care Network member (HMO), both the subscriber and adult dependents can fill out the form.

After you complete your form

We'll send you a confirmation email after you submit the form. The form takes five business days to process. During that time you can't make changes to the form.

Whenever you add or drop other health insurance, tell us about it by filling out this form again.

How else can I complete my Coordination of Benefits form?

If you are a Blue Cross Blue Shield of Michigan member (PPO/traditional), you can also mail or fax the Coordination of Benefits form (PDF)​ to us.

Blue Care Network members (HMO) must complete the form online.