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Important Forms
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Traditional 70/30 Plan for Active Employees
Important Forms

Below are several forms you may need in communicating with the State Health Plan about your benefits. 

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 OptionsSM 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.

Reimburse the State 

Pursue claims paid by the State Health Plan where a third party is liable.

If you are injured as the result of an auto accident or other mishap caused by another person, your medical expenses will usually be covered by that person (often his or her auto or property insurance company). However, your immediate medical expenses will be covered by the State Health Plan while you wait for the other person to pay your expenses. Once you receive money from the other person, use the Overpayment form below to reimburse the State Health Plan for charges already paid. 

Overpayment Form
Use this form to repay the State Health Plan if your medical expenses are paid for by both a third party and the State Health Plan. Such duplicate payments typically occur as a result of incidents such as auto accidents in which a third party is liable for your health expenses. This information allows the Plan to properly credit members' accounts and pursue other claims paid by the Plan where a third party is liable. 

Continuation of Coverage Rights Under COBRA
This explains COBRA continuation rights when health benefit plan coverage would otherwise end because of a life event known as a "qualifying" event. 

Subrogation – Third Party Recovery

The State Health Plan ("Plan") has the right of subrogation upon its injured members' right to recover from liable third parties. The Plan's objective is to recover medical expenditures incurred by the Plan where a third party is liable for the care. 

Please 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% of its lien. The Plan collects fifty (50%) percent of the total damages recovered by members after reasonable costs of collection have been subtracted from the total recovery.

Members 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 request to NCSHP@hms.com. Alternatively, members may complete and fax the Lien Request form to 919-714-8575. Within five (5) business days HMS will provide a lien amount to members or their duly authorized representatives.

A Third Party Recovery Overpayment form is to be completed by providers for any overpayments due back to the Plan when a third party liability carrier has also paid the same claims. 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​.