Blue cross blue shield massachusetts reimbursement form

Here you'll find the forms most requested by members. To download the form you need, follow the links below.

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Appeal and Grievance form [PDF]

• 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.

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

Blue Cross Blue Shield Global Core® Brochure [PDF]
An informational guide for Blue Cross members, traveling within the United States or abroad. BlueCard®’ and Blue Cross Blue Shield Global® Core ensure you have access to top doctors and hospitals and concierge-level service.

Open Enrollment Waiver Form [PDF]
If you did not purchase health insurance during open enrollment period, you may request a waiver, visit mass.gov.

Transition of Care for New Members [PDF]
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. 

Transition of Care/Continuity of Care Request Form [PDF]
This form can be used for a Blue Cross Blue Shield of Massachusetts member* who is:

• - New to the plan and is receiving ongoing treatment from a provider that is not part of the Blue Cross network; or
• - Receiving ongoing treatment from a provider that has recently left the Blue Cross network; or
• - Using a tiered provider network and is receiving ongoing treatment from a provider that has moved to the highest cost-sharing tier.

*This form does not apply to Medicare HMO Blue® or Federal Employee Plan (FEP) members.

When you are billed for services from a provider that does not directly submit a claim to the local Blue Cross Blue Shield plan you may submit that claim for reimbursement.

To use our paper forms, download the appropriate form by clicking the links below and follow the instructions on the form.

Dental Claim Form [PDF]

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

EyeMed Claim Form [PDF]

A form for submitting a vision claim for Medicare subscribers who have EyeMed as their routine vision benefits administrator.

Medical Claim Form [PDF]

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

Medex®´ Subscriber Claim Form [PDF]

A form for submitting a claim for Medex subscribers with instructions on filing a claim.

Medicare Advantage Subscriber Claim Form [PDF]

A form for submitting a claim for Medicare Advantage subscribers with instructions on filing a claim.

COVID-19 At-Home Test Reimbursement form [PDF]

Eligible members can complete the COVID-19 At-home Test Reimbursement.

International claims form for care received outside of the U.S., Puerto Rico and the U.S. Virgin Islands.

International Claim Form [PDF]
A form for members submitting a medical claim when the care is received outside of the U.S., Puerto Rico, and the U.S. Virgin Islands.
*Medicare Advantage members please use Medicare Advantage Subscriber Claim Form above.

Reproductive Health Travel Benefit Reimbursement Form [PDF]

You may be eligible for reimbursement for certain travel expenses related to obtaining abortion services. To find out if you’re eligible, contact Member Services at 1-888-420-4501.

As a health care organization, we believe strongly that our members should have access to the care they need and want. To support our members in states where abortion access is legally restricted, we are reimbursing certain travel and lodging expenses related to abortion services (either surgical or medication-assisted). See our public statement.

Travel Benefit Reimbursement Form [PDF]

This benefit reimburses you for certain travel and lodging expenses related to obtaining covered services that are not available within 100 miles of your home. To find out if you’re eligible for this benefit, call Member Service at 1-888-420-4501.

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

To see your Form 1099-HC from the last two years, sign in to MyBlue and, click My Inbox and then Documents. Or you can click directly from here. View My Tax Form.

04-1045815 is the Federal Tax ID (FID) for Blue Cross Blue Shield of Massachusetts for Health Care tax filing purposes.

You won't receive a Form 1095-HC if:

• You're under 18 years old
• You have a dental and/or vision-only plan through Blue Cross
• You're enrolled in Medex®' or one of our Medicare Advantage plans

View Sample Form 1099-HC

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.

Your Form 1095-B states which months in 2020 you had health care coverage that meets the minimum essential coverage standards set by the federal government under the Affordable Care Act.

You won't receive a Form 1095-B if:

• You're a member of a self-funded plan
• You're a member with dental-only and/or vision-only plans through Blue Cross
• You're enrolled in Medicare Part B or one of our Medicare Advantage plans
• You're enrolled in a Health Savings Account plan
• You're enrolled in wellness programs that are part of minimum essential coverage

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.