CLAIMS INFORMATION FOR NON-U.S. PARTICIPANTS

A NEW COORDINATION OF BENEFITS FORM IS REQUIRED EACH YEAR

If you have not completed a Coordination of Benefits form within the past year, you will need to do so before your claims can be processed. Each year, a Coordination of Benefits form is mailed to you during your open enrollment period. If the Health Plan has not received a current Coordination of Benefits form, even if your information has not changed, your claim may be denied.

This page includes instructions on how to file a claim for medical, prescription, dental and vision services received outside the United States.

For instructions on how to file your claim, click your claim type from the list below:

To submit a medical claim for services received outside the U.S., follow the three steps below.

Step 1: Download the Claim Form – Medical – Services Received Outside the U.S.

This is the Blue Cross Blue Shield Global Core International Claim Form. You should submit the completed form along with any itemized bill you might have.

Step 2: Be sure your claim submission includes both a completed Blue Cross Blue Shield Global Core International Claim Form and an itemized bill with all information listed below.

If you do not provide all of the required information, your claim could be delayed.

  • Health Plan Participant’s Information
    • Name
    • Health Plan ID Number (as it appears on your Health Plan ID Card)
    • Health Plan Group Number
  • Patient’s Information
    • Name
    • Date of Birth
  • Provider’s Information
    • Name
    • Address
    • Federal Tax ID Number
  • Service Information
    • A Description of Services and Diagnosis (provided by the doctor).
    • Amount Paid/Proof of Payment

Step 3: Submit your claim to Blue Cross Blue Shield Global Core using the information below.

It is recommended that you submit your claim by email, mobile app or online in order to have proof of your claim submission.
  • By email: claims@bcbsglobalcore.com
  • By mobile phone: Download the Blue Cross Blue Shield Global Core mobile app     For Android     For iOS
  • Online:  www.bcbsglobalcore.com
  • By mail: DO NOT submit claims to the Health Plan Office. Mail your claim directly to Blue Cross at the address below:
    • Service Center
    P.O. Box 2048
    Southeastern, PA  19399

If you have any questions regarding your medical claim submission, you can reach Blue Cross Blue Shield Global Core at (800) 810-BLUE or collect at (804) 673-1177.

Step 4: The Health Plan will determine the portion of the claim’s billed amount the Health Plan will pay under its terms.

You will be reimbursed the Reasonable and Customary rate according to the New York City metropolitan area. If you disagree with the reimbursement amount, you may file an appeal with the Health Plan to have the reimbursement amount reviewed.

To be eligible for coverage under the Health Plan’s prescription drug benefit, a medication must be available in the United States and have received FDA approval. If you are unsure if the medication is FDA-approved, you can call CVS Caremark at (855) 271-6601.

Step 1: Fill out the Prescription Drug Claims Form.

  • In the Group /Group Name field, write in the RxGRP from your CVS Caremark prescription card.
  • In the Identification Number field, write in the ID that appears on your CVS Caremark prescription card.

Step 2: Be sure to include prescription receipts with your claim form.

Step 3: Mail the completed form and additional information to:

  • By mail:
    DO NOT submit claims to the Health Plan Office.
    Mail your claim directly to CVS Caremark at the address below:

    CVS Caremark
    P.O. Box 52136
    Phoenix, AZ 85072-2136

If you have any questions regarding your claim, call the Health Plan Office at (323) 866-2200, Ext. 401.

You must complete one claim form for each submission and should not combine more than one family member per a claim form.

All foreign dental claims should be filed with Delta Dental, the Health Plan’s dental benefit manager.

Step 1: Fill out the Dental Plan Claims Form.

Complete sections 1-15 of the form.

  • For Section 9, Employer (Company) Name, write in “DGA-PPHP.”
  • For Section 10, Group Number, write in “0480.”

If you do not have a U.S. social security number, you can either call our office for the alternate social security number we assigned to you for identification purposes or enter your “Enrollee Number” which appears on your Delta Dental coverage card.

Step 2: Attach a copy of the dentist’s statement of treatment to the claim form.

The statement of treatment should include the dentist’s name, phone number, a description of each service the dentist performed, and the amounts billed and paid for each service.

Step 3: Mail the completed form and statement to:

Delta Dental
P.O. Box 997330
Sacramento, CA 95899-7330

If you have any questions regarding your claim, call Delta Dental at (415) 972-8300.

All foreign vision claims should be filed with Vision Service Plan, the Health Plan’s vision benefit manager.

Step 1: Fill out the VSP Out of Network Reimbursement Form.

Step 2: Submit the completed form and itemized receipts.

  • By email  (RECOMMENDED):
    rebekah.mcgaughey@vsp.com
    NOTE: It is recommended to email or fax your claims in order to have proof of your claim submission.
  • By fax  (RECOMMENDED):
    (916) 858-5588
    NOTE: It is recommended to email or fax your claims in order to have proof of your claim submission.
  • By mail:
    DO NOT submit claims to the Health Plan Office.
    Mail your claim directly to VSP at the address below:

    Vision Service Plan
    P.O. Box 495918
    Cincinatti, OH  45249-5918

If you have any questions regarding your claim, call VSP at (916) 635-7373.