Member Secured Services

Master Medical claim checklist

If your Blue Cross Blue Shield of Michigan coverage has been transferred to the new system, follow these guidelines to file a Master Medical claim for prescription drugs or for services paid to a nonparticipating provider.

• Your benefit level will depend on the coverage you have through your group plan.
• Do not delay submitting services for payment. File a claim each time you receive covered services. Claims submitted more than 180 days after the end of the year in which the services were provided are not eligible for payment.
• Fill out the Member Application for Payment form (PDF) completely.
• Attach the original receipts from your provider. We cannot accept cash register tapes, cancelled checks or money order stubs. We cannot return the receipts to you. Be sure to send us the original receipts and keep copies for yourself.
• Be sure your receipts and claim forms contain:
  • Subscriber (cardholder) name and contract number
  • Patient's name
  • Date of service
  • Provider name, address and tax identification number
  • Description of service (HCPCS or procedure code)
  • Diagnosis
  • Charge (itemize charges if more than one service is on a receipt)
• Separate receipts, forms and vouchers for each member. Complete a separate claim form for each member.
• Staple or paper clip receipts to the appropriate claim form. Please do not glue or tape.
• If applicable, attach a copy of your Explanation of Medicare Benefits form or Medicare voucher.

Mail the claim form and receipts to the address printed on the top right corner of the claim form.