Important Forms Below are several forms you may need regarding your State Health Plan benefits. Eligibility and Enrollment Support Center Authorization Request Form If you wish to authorize a person or entity to receive your personal health information (PHI) from the Eligibility and Enrollment Support Center on your behalf, please complete this form. Member/Dependent Authorization Request Form If you wish to authorize a person or entity to receive your PHI from Blue Cross and Blue Shield of NC on your behalf, please complete this form. Coverage Request for a Dependent Child with a Disability If you have a child over age 26 who is eligible as a mentally or physically incapacitated dependent, complete this form. If you wish to authorize a person or entity to receive your PHI, please complete this form. Authorize a Representative – Appeals Use this form to allow a third party to appeal a denied claim or denied certification on your behalf. Attach this form to the Appeals Form. Flexible Benefit Plan (Section 125) Rejection Form Learn how to opt out of the Flexible Benefit Plan, IRS Section 125. Medication Extended Day Supply Request Form Plan members who will be traveling outside of the United States 90 days or more may request an extended day supply of medication. Members may request additional refills by completing the Medication Extended Day Supply Request Form, and emailing it to SHPEDSR@nctreasurer.com 30 days prior to their scheduled departure date. Please notify your provider of your plans. The policy is available by clicking here. Request Reimbursement In most cases, health care providers and pharmacies will file your insurance claims for you, and you will pay only your copay out of pocket. However, providers who are not part of the State Health Plan network will ask for full payment directly from you. In those cases, if the services are normally covered by the State Health Plan, you can request that your expenses be reimbursed. Use the appropriate form below to request reimbursement from the State Health Plan. PPO Plan Medical Claim Form Use this form to request reimbursement for health care services, such as a visit to a doctor not in the Blue Options provider network. The Plan will only reimburse you up to the allowable, usual, customary, reasonable amount. Non-participating providers may bill you for the remainder of their charges. PPO Worldwide International Claim Form Use this form to request reimbursement for health care services when you receive care outside of the United States. Prescription Drug Claim Form Use this form to request reimbursement for prescription drugs, such as those not purchased from a pharmacy contracted with the State Health Plan. Your reimbursement will be the Plan's maximum allowable amount, not the charge for the prescription drug.
Important Forms Below are several forms you may need regarding your State Health Plan benefits. Eligibility and Enrollment Support Center Authorization Request Form If you wish to authorize a person or entity to receive your personal health information (PHI) from the Eligibility and Enrollment Support Center on your behalf, please complete this form. Member/Dependent Authorization Request Form If you wish to authorize a person or entity to receive your PHI from Blue Cross and Blue Shield of NC on your behalf, please complete this form. Coverage Request for a Dependent Child with a Disability If you have a child over age 26 who is eligible as a mentally or physically incapacitated dependent, complete this form. If you wish to authorize a person or entity to receive your PHI, please complete this form. Authorize a Representative – Appeals Use this form to allow a third party to appeal a denied claim or denied certification on your behalf. Attach this form to the Appeals Form. Flexible Benefit Plan (Section 125) Rejection Form Learn how to opt out of the Flexible Benefit Plan, IRS Section 125. Medication Extended Day Supply Request Form Plan members who will be traveling outside of the United States 90 days or more may request an extended day supply of medication. Members may request additional refills by completing the Medication Extended Day Supply Request Form, and emailing it to SHPEDSR@nctreasurer.com 30 days prior to their scheduled departure date. Please notify your provider of your plans. The policy is available by clicking here. Request Reimbursement In most cases, health care providers and pharmacies will file your insurance claims for you, and you will pay only your copay out of pocket. However, providers who are not part of the State Health Plan network will ask for full payment directly from you. In those cases, if the services are normally covered by the State Health Plan, you can request that your expenses be reimbursed. Use the appropriate form below to request reimbursement from the State Health Plan. PPO Plan Medical Claim Form Use this form to request reimbursement for health care services, such as a visit to a doctor not in the Blue Options provider network. The Plan will only reimburse you up to the allowable, usual, customary, reasonable amount. Non-participating providers may bill you for the remainder of their charges. PPO Worldwide International Claim Form Use this form to request reimbursement for health care services when you receive care outside of the United States. Prescription Drug Claim Form Use this form to request reimbursement for prescription drugs, such as those not purchased from a pharmacy contracted with the State Health Plan. Your reimbursement will be the Plan's maximum allowable amount, not the charge for the prescription drug.
