Forms

Appeal and Grievance form

• Request an appeal if you feel we didn’t cover or pay enough for a service or drug you received.
• Request a grievance if you have a complaint against Blue Cross or your health care provider.

Authorization for release of information, designation of a personal representative, and more.

 

Debit Authorization Recurring Payment Authorization
Schedule your payment to be automatically deducted from your bank account.

 

Deceased Member Affidavit
A form used for claim reimbursement by the surviving spouse or next of kin of a deceased subscriber.

 

Direct Pay Application for a Membership Change Pay
A form to make changes to Direct Pay after a membership change due to circumstances such as marriage, divorce, birth of a child, or loss of eligibility.

 

Documentation of Legal Representative Status for Member
A form documenting the legal authority of an individual to act on a member’s behalf in making decisions about the member’s health care.

 

Member’s Request for an Accounting of Disclosures
A form to request accounting of certain disclosures of your protected health information.

 

Member’s Designation of an Authorized Representative
A form designating an individual as your authorized representative, who may discuss and receive information regarding your health care coverage provided through Blue Cross Blue Shield of Massachusetts.

 

Member’s Request to Amend Protected Health Information
A form to request an amendment to Protected Health Information (PHI) that Blue Cross Blue Shield of Massachusetts maintains in a designated record set.

 

Permission for One-Time Disclosure of Information
A form authorizing Blue Cross Blue Shield of Massachusetts to send specific information to a specific individual.

 

Renewal Audit Package
You and your dependents must live in Massachusetts to renew your individual health plan with Blue Cross Blue Shield of MA. Use this form to show your eligibility.

 

Request for Access to or Copies of Protected Health Information in Designated Record Set
A request form to inspect or obtain copies of your protected health information in the designated record set that Blue Cross and Blue Shield of Massachusetts maintains.

 

Retaining Coverage for Disabled Dependent Child
A form to request coverage a psychologically or physically disabled dependent child.

 

Student Certificate Affidavit
A form that certifies that your child is a full-time student at an accredited school. This allows them to continue to be eligible for health coverage under your policy.

 

Student Medical Leave Affidavit Form
This form certifies that your student dependent is on a medically necessary leave of absence from a post-secondary school.

 

Transgender Services
A form detailing how to request Prior Authorization, or pre-approval, before gender affirming (transgender) services.

Dental claims, subscriber submit claim, Medicare Part D appointment of representative, and more.

 

Blue Cross Blue Shield Global Core^®
The Blue Cross Blue Shield Global Core form is used to submit institutional and professional claims for benefits for covered services received outside the United States, Puerto Rico, and the U.S. Virgin Islands.

 

International Claim Form
A form for submitting a medical claim when the care is received outside of the U.S., Puerto Rico, and the U.S. Virgin Islands.

 

Continuity of Care Request Form
Complete this form if your doctor is leaving our network and you're receiving treatment for a serious, chronic, or acute medical condition. You may qualify to continue your in-network care for a defined period of time or treatment.

 

Continuity of Care - For Members with a New Hampshire PCP
Our tiered or limited-network plans include a benefit for certain members with a serious health condition, such as cancer or cystic fibrosis.

 

Continuity of Care Form for Plans That Include Tiered-Provider and Limited-Provider Networks
Our tiered or limited-network plans include a benefit for certain members with a serious health condition, such as cancer or cystic fibrosis.

 

Dental Claim Form
A form for submitting a dental claim with instructions on filing a claim.

 

Enhanced Dental Benefits Enrollment Form
Your dental coverage policy must include Enhanced Dental Benefits in order to be eligible for coverage.

 

Medex^®´ Subscriber Claim Form
A form for submitting a claim for Medex subscribers with instructions on filing a claim.

 

Subscriber Claim Form
A form for submitting a medical claim with instructions on filing a claim.

 

Transition of Care for New Members
Use this form if you want Blue Cross Blue Shield of Massachusetts to consider short-term coverage, at the in-network level of benefits, with your current out-of-network provider. This gives you some time to transition your care to an in-network provider.

Please note: This form does not apply to Medicare HMO Blue^® or Federal Employee Plan (FEP) members. *Blue Cross refers to Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross and Blue Shield of Massachusetts HMO Blue^®, Inc., and/or Massachusetts Benefit Administrators LLC, based on Product participation. MPC_061319-2B-2 (11/19) Transition of Care

 

Vision Claim Form
A form for submitting a vision claim, with instructions for filing a claim.

Fitness Reimbursement Form
A form to claim your reimbursement on qualified health club membership fees.

 

Fitness Reimbursement Form* (Spanish)
A form to claim your reimbursement on qualified health club membership fees.

 

Living Healthy Smoke-Free—Break Away from the Pack Brochure
20 facts about smoking, reasons to quit, and smoking myths.

 

Weight-Loss Reimbursement Form*
A form to claim your reimbursement on a qualified weight-loss program.

 

Weight-Loss Reimbursement Form* (Spanish)
A form to claim your reimbursement on a qualified weight-loss program.

 

*Reimbursements vary. Please refer to your Summary of Benefits to confirm your reimbursement amount.

Pharmacy claim form and request for Prior Authorization form.

 

Express Scripts^®´´, Inc. Prescription Drug Claim Form
To request reimbursement for a prescription from Express Scripts, you must download, print, fill out this form, and submit it together with your receipts to Express Scripts.

 

Massachusetts Standard Form for Medication Prior Authorization Requests
Your doctor can use this form to request prior authorization or an exception to have your medication covered.

Qualifying members will receive tax forms that serve as proof of health insurance coverage.

Form 1099-HC

We'll provide the 2020 Form 1099-HC to qualifying members who were enrolled in a Blue Cross Blue Shield of Massachusetts plan at any time during the calendar year. If you qualify, you'll receive your form:

• Via mail, postmarked by January 31, 2021
• On their MyBlue account, added on January 31, 2021

View Sample Form 1099-HC

To see your Form 1099-HC from the last two years, sign in to MyBlue and select tax forms

If you haven't received your 1099-HC by the first week of February, 2021, please call Member Service at the number on the front of your ID card.

Form 1095-B

We'll provide the 2020 Form 1095-B to qualifying members who were enrolled in a Blue Cross Blue Shield of Massachusetts plan at any time during the calendar year. The form will be postmarked by January 31, 2021.

If you haven't received your 1095-B by the first week of February, 2021, please call Member Service at the number on the front of your ID card.

Additional Tax Forms

In addition to Form 1099-HC and Form 1095-B, there are other health care-related tax forms that you won’t receive from Blue Cross. The deadline to provide these forms to qualified members is January 31.

Form 1095-A

Form 1095-A, or the Health Insurance Marketplace Statement, is for people who have health insurance through the Massachusetts Health Connector or an ACA Marketplace plan. This form will be provided to qualified members by their plan.

If you have a health plan through the Massachusetts Health Connector and haven’t received your Form 1095-A by January 31, visit Health Care Connector

Form 1095-C

Form 1095-C is for people who receive health insurance from their employer. This form will be provided to qualified members by their employer.

If you have employer-provided health insurance and haven’t received your Form 1095-C by January 31, please contact your employer or HR department.