Who is this for?
If you recently visited a doctor outside of your network and you need to submit a claim, you can use one of these claim forms.
Even if you have medical, vision, dental or prescription drug coverage through Blue Cross Blue Shield of Michigan or Blue Care Network, there may be occasions when you have to pay for services yourself. For example, you have to see an out-of-network doctor that doesn’t accept your insurance.
You can use these claim forms to ask us for reimbursement. Just choose the form based on your group or plan and the service. You’ll go to a page that explains the form and has a link to download it. Sometimes the form is called Member Application for Payment Consideration, which is the same as a claim form. If you were on a cruise, you'll use the same claim form for reimbursement of medical expenses.
If you have any questions, call the phone number on the back of your enrollee ID card or contact us and we'll help.
Traveling in a different state?
You may need to visit a doctor or hospital while traveling in another state. If you do, the BlueCard® Program will help you get access to doctors and hospitals that participate with Blue Cross Blue Shield.
If you go to an out-of-state doctor or hospital that doesn’t participate with Blue Cross Blue Shield, you may pay upfront for services. To file a claim for those out-of-network services, you’ll need to use the claim form from the state where you were treated. Check the state-by-state list of Blue Cross Blue Shield companies to get started.
Traveling outside of the U.S.?
Because you’re insured through Blue Cross Blue Shield of Michigan, you have access to the BlueCard Worldwide® Program.
If you have to pay for medical services while out of the country, they have a claim form available you can use to ask for reimbursement for medical expenses you paid for while out of the country.
You'll need your enrollee ID card to log in to the site.
Follow these instructions to log in and get the Internal Claim Form:
- Enter the first three letters from your enrollee ID card
- Click Go
- On the next page, select Claim Forms
- Choose the appropriate international claim form