Coverage - Benefit Description

 
Participant Forms

Claim Form
This Blue Cross and Blue Shield of Texas (BCBSTX) claim form should be used when filing for reimbursement for medical services.

If you need assistance completing this form, please contact BCBSTX Customer Service at (800) 252-8039.


Primary Care Physician (PCP) Selection Forms
You can either complete the GBP Supplement Form to select or change your PCP or call BCBSTX Customer Service at (800) 252-8039.  Your selection will be effective the day you call BCBSTX Customer Service or the date you sign your form.

Please send completed PCP Forms to:

BCBSTX
Membership/Group Accounts
PO Box 6109
Abilene, TX 79608-9986

If you need assistance with completing this form, please contact BCBSTX Customer Service at (800) 252-8039.

New employees: Please wait until 30 days prior to your effective date to send GBP Forms.


 

Prescription Drug Forms
These Medco claim forms should be used when filing for reimbursement for a prescription drug or when using the mail-order program.

If you need assistance in completing your prescription drug forms, please contact Medco Customer Service at (800) 903-8345.


HIPAA Authorization Form to Disclose PHI
Under the HIPAA Privacy Rule, an individual may authorize release of his or her protected health information (PHI) to a specific person.  You must complete the authorization form for BCBSTX to disclose PHI.


Once completed, please mail this form to:
BCBSTX
PO Box 660044
Dallas, TX 75266-0044

If you need assistance with completing this form, please contact BCBSTX Customer Service at (800) 252-8039.


Transitional Benefits
Transitional Benefits only apply to new members to HealthSelect. 

If you need assistance with completing this form, please contact BCBSTX Customer Service at (800) 252-8039.


Fraud and Abuse

Insurance fraud costs you money. Learn about what you can do if you suspect fraud.

 

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