Below are several forms you may need in communicating with the State Health Plan about your benefits.
Coverage Request for Incapacitated DependentIf you have a child over age 26 who is eligible as a mentally or physically incapacitated dependent, complete this form.
Member/Dependent Authorization Request FormIf you wish to authorize a person or entity to receive your PHI, please complete this form.
Authorize a Representative – AppealsUse this form to allow a third party to appeal a denied claim or denied certification on your behalf.
Flexible Benefit Plan (Section 125) Rejection FormLearn how to opt out of the Flexible Benefit Plan, IRS Section 125.
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 FormUse 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.
note that in accordance with North Carolina General Statute (N.C.G.S.) §
135-48.37, the Plan is required to inquire about the terms of any third
party recovery and disbursement to all lien holders if payment to the
Plan is less than 100 percent of its lien. The Plan collects 50 percent
of the total damages recovered by members after reasonable costs of
collection have been subtracted from the total recovery.
should contact Health Management Systems Inc. (HMS), which has been
contracted by the Plan to perform subrogation services, at 800-294-2757
to determine whether the Plan is claiming a right to recovery. Members
or their duly authorized representatives can also email subrogation
requests to firstname.lastname@example.org.
For a complete copy of N.C.G.S. § 135-48.37, which governs the Plan's right of subrogation and right of recovery, please click here.