Forms

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• Medicare

  Drug claims & reimbursements, special medicine requests

  • Appointment of Representative

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    APPOINTMENT OF REPRESENTATIVE

    Appoint a person to file a grievance, request a coverage determination, or request an appeal on your behalf.

    If additional help is needed, call: 1-800-633-4227.

    Quick Start

    1) You and the person accepting the appointment must fill out this form and submit it with the request.

    2) Your doctor may request: a coverage determination, redetermination, or Independent Review Entity (IRE) reconsideration, on your behalf, without having to be an appointed representative.

    3) Send this form to the same address where you are sending your: appeal, grievance, initial determination, or decision.

  • Medicare Advantage Member Submitted Health Insurance Claim Form

    For Medicare Advantage Medical Claims Only. May be called: Health Insurance Claim, Medical Claim Form.

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    1. You must submit a copy of your receipt(s) and an itemized bill from your provider.

    The itemized bill should include the provider’s name, address, and the types of services provided.

    2. All expenses for 1 patient can be submitted with the same claim form.

    You must use a separate claim form for each patient.

    3.  Use blue/black ink and do not use highlighters.

    Use this form to submit requests for repayment for health care provided by out-of-network providers.

    Mail this form and required documentation to:

    Highmark Inc.

    P.O. Box 1068

    Pittsburgh, PA 15230-1068

  • Medicare Part D Coverage Determination Request Form

    May be called: CMS Coverage Determination Provider Form, Medicare Coverage Determination.

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    Quick Start

    1.  This form cannot be used to request Medicare non-covered drugs.

    2.  Medicare non-covered drugs includes:

    barbiturates, benzodiazepines, fertility drugs, prescription weight loss medication, weight gain or hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

    3. This form cannot be used to request biotech or other specialty drugs for which drug-specific forms are required.

    You, your appointed representative, or your doctor may use this form to request a coverage determination, including an exception, from a plan sponsor, for your Medicare Part D Coverage.

    Mail this form to: 

    Express Scripts

    ATTN: Medicare Part D

    P.O. Box 14718

    Lexington, KY 40512-4718

    Or, fax this form to: 1-608-741-5483

  • Medicare Part D Hospice Prior Authorization Information

    May be called: Request for Prescription Medication for Hospice.

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    Quick Start

    1. This form covers drugs that should not be covered under the Medicare Part A Hospice Benefit.

    2.  Submit a separate form for each medication.

    3.  Signature of hospice representative or prescriber is required.

    Use this form to request coverage of medications for individuals in hopsice care.

    Mail this form to:

    Medical Managment & Policy

    120 Fifth Avenuce, MC P4207

    Pittsburgh, PA 15222

  • Medicare Part D Prescription Drug Claim Form

    May be called: General Prescription, Vaccine Administration.

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    Quick Start

    1. Fill in the cardholder information section completely.

    2.  If Medicare Part D is your primary prescription drug coverage, then skip section 2.

    3.  You should keep detailed notes on pharmacy and doctor information.

    This form can be used to request reimbursement for prescription drugs purchased without using your Member ID card.

    Mail this form and documentation to: 

    Express Scripts

    ATTN: Medicare Part D

    P.O. Box 14718

    Lexington, KY 40512-4718

    Or, fax this form and documentation to:  1-608-741-5483

  • Request for Medicare Prescription Drug Coverage Determination

    May be called: Medicare Prescription Coverage Request.

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    Quick Start

    1.  Your prescriber may ask for coverage determination, on your behalf

    2.  If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative.

     

    3. You should keep detailed notes on pharmacy, diagnosis, and doctor information.

    You, your appointed representative, or your doctor may use this form to request a coverage determination, including an exception, from a plan sponsor.

    Mail this form and documentation to:

    Medical Management & Policy

    120 Fifth Avenue

    Mail code P4207 

    Pittsburgh, PA 15222

    Or, fax this form and documentation to: 1-866-240-8123

  • Request for Redetermination of Medicare Prescription Drug Denial

    May be called: CMS Redetermination Request Form.

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    Quick Start

    1.  You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask for a redetermination.

    2. Your doctor may ask us for an appeal on your behalf.

    3.  If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative.

    You, your appointed representative, or your doctor may use this form to request a redetermination (appeal) from a plan sponsor.

    Mail this form and documentation to: 

    Appeals & Grievance Department

    P.O. Box 535047

    Pittsburgh PA 15253-5047

    Or, fax this form and documentation to: 1-717-635-4209

• Medical

  Claims and reimbursement, records transfer, and more.

  • Authorization for Disclosure of Health Information

    May be called: Authorization to Release Health Plan Information.

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    Quick Start

    1. In most cases, Highmark is the "Releasor."

    2. You should set a time span of the form.

    If you don't, this authorization ends in 1 year.

    3. You will need detailed information on the person/entity who will receive your information.

    Share information about your health plan coverage or claims with whomever you choose. 

    Mail this form to: 

    Highmark Inc.,

    Customer Service 

    P.O. Box 890035

    Camp Hill, PA 17089-0035

  • Childbirth Education Class Reimbursement Form

    May be called: Family Health Planning Reimbursement Claim.

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    Quick Start

    1. You must have active medical coverage when you take the class.

    2. You need to attend at least 75% of the classes.

    Teacher's signature is required as proof.

    3. To verify your payment, you need to include copies of all receipts.

    Get reimbursed up to $65 for going to Childbirth Education Classes.

    Mail this form with receipt to:

    Baby Blueprints

    Attn: Childbirth Education Class

    P.O. Box 890035

    Camp Hill, PA 17089-0035

  • Coordination of Benefits

    May be called: COB, Other Insurance.

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    Coordination of Benefits

    1. The information you provide is private. It will only be used for claims.

    2. You will need detailed information on the policy holder and their coverage.

    Have more than on insurance plan? Tell us about all of your insurance coverage here so that the right plan gets billed the correct amount.

    Mail this form to:

    OPL Producation

    PO Box 890384

    Camp Hill, PA 17011-9732

  • International Claim Form

    May be called: International Health Insurance Claim.

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    Quick Start

    1. You must submit copies of receipts and medical records, if available.

    2. Complete all fields.

    Mark fields "N/A" if you have nothing to enter.

    3. If you have an outstanding balance, this form also has payment instructions.

    Use this form to file a claim for health care that you get outside of the U.S., Puerto Rico, and/or the U.S. Virgin Islands. 

    Mail this form and documentation to:

    Service Center

    P.O. Box 2048

    Southeastern, PA 19399

    Or, email this form and copies of documentation to: claims@bcbsglobalcore.com

  • Patient Request for Medical Records Transfer

    May be called: Medical Records Transfer.

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    Quick Start

    1. You do not submit this form to Highmark directly.

    2. If a personal representative must sign, attach documentation of representation (e.g., Power of Attorney, Legal Guardianship).

     

    3. You will need detailed mailing information for the recipient and sender.

    Share your health history with the doctor/practice you select. Submit this form when you want to move your medical records from one doctor/practice to another.

    Give this completed form to the doctor/practice sending the medical information.

  • Member Submitted Health Insurance Claim Form

    May be called: Health Insurance Claim, Medical Claim Form.

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    Quick Start

    1. You must submit copies of receipts.

    You will also need detailed notes on doctor, care, transportation, and medication to help you itemize your bill.

    2. All expenses for 1 patient can be submitted with the same claim form.

    You must use a separate claim form for each patient.

    3. Use black/blue ink and do not use highlighters.

    Please write in all capital letters.

    This is one of the most commonly submitted forms. Use it to process requests for repayment for out-of-network health care.

    Mail this form and documentation to:

    Claims

    P.O. Box 890173

    Camp Hill, PA 17089-0173

  • Member Submitted Major Medical Insurance Claim Form

    May be called: Major Medical Claim, Major Medical Health Insurance Plan Claim.

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    Quick Start

    1. You must submit copies of receipts.

    You will also need detailed information on your doctor and care, to help itemize your bill.

    2. If you have an Explanation of Benefits, attach it with other documentation.

    3. All expenses for 1 patient can be submitted with the same claim form.

    Use this form to file a claim if you have Major Medical Insurance.

    Mail this form and documentation to:

    Highmark Major Medical

    P.O. Box 890393

    Camp Hill PA 17089-0393

  • Medicare Advantage Member Submitted Health Insurance Claim Form

    For Medicare Advantage Medical Claims Only. May be called: Health Insurance Claim, Medical Claim Form.

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    1) You must submit a copy of your receipt(s) and an itemized bill from your provider.

    The itemized bill should include the provider’s name, address, and the types of services provided.

    2) All expenses for 1 patient can be submitted with the same claim form.

    You must use a separate claim form for each patient.

    3) Use blue/black ink and do not use highlighters.

    Please write in all capital letters.

    Use this form to submit requests for repayment for health care provided by out-of-network providers.

    Mail this form and required documentation to:

    Highmark Inc.

    P.O. Box 1068

    Pittsburgh, PA 15230-1068

• Automatic Premium Payment

  Enroll in online E-bill, or set up Electronic Funds Transfers, to automatically pay your monthly insurance bill.

  • Automatic Payment Options

    May be called: Regional Premium Payment Form.

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    Quick Start

    1. Choose eBill.

    To use this feature, sign up online.

    2. Choose EFT.

    To use this feature sign up through the mail.

    3. It takes 6-8 weeks for EFT set up and you must continue to pay your premium payments by another method during this time.

    Sign up to safely and automatically pay your health insurance bill.  Save time by using either eBill or Electronic Funds Transfer (EFT).

    Mail EFT Form to: 

    Highmark Enrollment Department

    P.O. Box 382185

    Pittsburgh, PA 15251-8185

• Vision

  Claims and reimbursement.

  • Eyewear Repair and Replacement Policies

    Explains what is/isn't covered when repairing/replacing your eyeglasses/contact lenses.

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  • Direct Reimbursement Claim Form

    May be called: Vision Claim & Reimbursement Form, Davis Vision Insurance Claim, Out-of-Network Vision Reimbursement Claim.

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    Quick Start

    1. Claim expenses include examinations and/or eyewear.

    2. You must submit copies of receipts.

    You will also need detailed treatment notes.

    3. All expenses for 1 patient can be submitted with the same claim form.

    You must use a separate claim form for each patient.

    Get repayment for vision care received outside of the Davis Vision network. 

    Mail this form to:

    Vision Care Processing Unit

    P.O. Box 1525

    Latham, NY 12110

• Pharmacy

  Claims, mail order, reimbursement, special medicine requests, and more.

  • Home Delivery Order Form (A) & Health Allergy & Medication Questionnaire (B)

    May be called: Mail Order Claim, RX/Prescription Mail Order Claim, Express Scripts Mail Order Claim.

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    Quick Start

    1. Check that your doctor has prescribed the maximum days' supply allowed by your plan (not a 30-day supply), plus refills for up to 1 year, if appropriate.

    This form helps you save money and time by having medication delivered to your front door.

    Mail these forms to the corresponding addresses:

    Home Delivery Order Form (A)

    Express Scripts

    P.O. Box 66577

    St. Louis, MO 63166-6577

    Health Allergy & Medication Questionnaire (B)

    Express Scripts

    HMQ Processing Center

    P.O. Box 66773

    St. Louis, MO 63166-6773

  • Mail Order Fax Form for Doctor

    May be called: Electronic Prescription Transfer, Express Scripts Mail Order Fax Form.

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    Quick Start
    

    1. Have your doctor complete this form.

    2. Have your doctor fax the form to our mail order pharmacy, on your behalf.

    3.  Keep your insurance information on hand.

    Request a new prescription from your doctor. Print and bring this form with you to your appointment.

  • Medicare Part D Prescription Drug Reimbursement Form

    May be called: Medication Reimbursement Claim, Retail Prescription Claim.

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    Quick Start

    1. You must complete a separate claim form for each pharmacy used and for each patient.

    2. You must submit claims within 1 year of purchase date, or as required by your plan.

    3. You must submit copies of receipts.

    You will also need detailed prescription information. Tape, do not staple, receipts to this form. Tape receipts to an additional piece of paper, if you have more than 3 receipts.

    Use this form when you have paid full price for a prescription drug at a retail pharmacy.

    Mail this form and documentation to:

    Express Scripts

    ATTN: Medicare Part D

    P.O. Box 14718

    Lexington, KY 40512-4718

     

    Or, fax this form to: 1-608-741-5483

  • Medication Exception Request

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    Quick Start

    1. Complete all fields to submit.

    2. You will be contacted by phone after your request is processed.

    3. You will need your doctor's contact information.

    Use this form to request coverage for medications that aren't part of your pharmaceutical plan.

  • Prescription Drug Medication Request Form

    May be called: Prescription Drug Medication, Prescription Request.

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    1. The prescribing physician (PCP or Specialist) should, in most cases, complete the form. You must send it.

    2. Submit a separate form for each medication requested.

    3. Provide the physician address used for notification, not just the regular mailing address (they may be the same).

    Some drugs require a medical review by your health plan before you can fill a prescription. Pharmacists call this a "prior authorization." Make this process easy by bringing this form with you to your appointment.  

    Mail this form to:

    Medical Management & Policy

    120 Fifth Avenue, MC P4207,

    Pittsburgh, PA 15222

    Or, fax this form to: 1-866-240-8123

  • Prescription Drug Reimbursement Form

    May be called: Medication Reimbursement Claim, Retail Prescription Claim.

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    Quick Start

    1. You must complete a separate claim form for each pharmacy used and for each patient.

    2. You must submit claims within 1 year of purchase date, or as required by your plan.

    3. You must submit copies of receipts.

    You will also need detailed prescription information. Tape, do not staple, receipts to this form. Tape receipts to an additional piece of paper, if you have more than 3 receipts.

    Use this form when you have paid full price for a prescription drug at a retail pharmacy.

    Mail this form and documentation to:

    Express Scripts

    ATTN: Commercial Claims

    P.O. Box 14711

    Lexington, KY 40512-4711

    Or, fax this form to: 1-608-741-5475

  • Specialty Drug Request Form

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    Quick Start

    1. The prescribing physician (PCP or Specialist) should, in most cases, complete the form.

    You must send it. Be sure to bring it to your appointment.

    2. Submit a separate form for each medication requested.

    3. Provide the physician address used for notification, not just the regular mailing address (they may be the same).

    Specialty drugs are used to treat complex and/or chronic conditions. Use this form to request access to high-end drugs.

    Mail this form and documentation to:

    Medical Management & Policy

    120 Fifth Avenue, MC P4207

    Pittsburgh, PA 15222

    Or, fax this form and documentation to: 1-866-240-8123

  • Step Therapy Exception Request Form

    May be called: Exemption from Alternative Therapy Request.

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    Quick Start

    1. Requires verification that you have tried an alternative therapy first.

    2. Or, requires your doctor to give documentation for why you can't take the alternative therapy.

    3. Step therapy may include select over-the-counter products.

    Use this form to request exception from step therapy if your doctor has documented that you are unable to try an alternative therapy.

  • Zostavax Prescription Drug Claim

    May be called: Shingles Vaccine Drug Claim.

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    Quick Start

    1. All expenses for 1 patient can be submitted with the same claim form.

    You must use a separate claim form for each patient.

    2. You must submit copies of your receipts.

    3. You do not have to itemize prescription drug expenses if you receive one from your pharmacy. That printout must include the pharmacist's stamp and signature.

    Not all doctors carry the shingles vaccine Zostavax. If you purchased the vaccine, and took it to your doctor to administer the shot, you can request payment with this form. 

    Mail this form and documentation to:

    Highmark Blue Shield 

    P.O. Box 890062 

    Camp Hill, PA 17089-0062

• Dental

  Claims and reimbursement.

  • Member Dental Claim Form

    May be called: United Concordia Health Claim, Out-of-Network Dental Reimbursement Claim.

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    Quick Start

    1. You will need detailed information for the dentist, including their license number.

    2. Keep records of the treatment, costs, and payment/receipts.

    3. Have your dental insurance plan information handy.

    Get repayment for out-of-network dental care. 

    Mail this form and documentation to:

    Address on back of your Member ID Card