Claims

BCBS Claim Form

Reimbursement for covered out-of-pocket medical expenses (excluding required copayments/coinsurance/deductible amounts) that you may have incurred inside the United States while actively covered under the Student Health Insurance Plan.

BCBS Dental Blue Claim Form

Reimbursement for covered out-of-pocket expenses (excluding required copayments/coinsurance) that you may have incurred while actively covered under the Dental Blue Plan.

BCBS International Claim Form

Reimbursement for covered out-of-pocket medical expenses (excluding required copayments, coinsurance, and deductible) that you may have incurred outside of the United States while actively covered under the Student Health Insurance Plan. Please use this form for services received before January 1, 2017.

BCBS Weight Loss Reimbursement Form

Reimbursement for qualifying weight loss programs.

Childbirth Classes

To receive your reimbursement for taking a childbirth course or refresher course, submit the claim form along with proof of payment and a copy of your completion certificate.

Prescription Drug Claim Form

The Blue Cross Blue Shield of Massachusetts prescription drug benefit is administered by Express Scripts® (ESI).  Use the ESI claim form to file a reimbursement for prescription expenses for which you paid out of pocket while actively covered under the Student Health Insurance Plan. You will not be reimbursed for applicable co-payments/coinsurance.

Enrollment forms

Dental

This enrollment application is for incoming students and those with a life changing event. Open enrollment ends February 28.

Post-Doc Affiliate Enrollment

Post-doctoral affiliates (also known as post-doctoral fellows) are eligible to enroll as long as they have a current appointment, were recently awarded a Ph.D. or equivalent doctorate in an appropriate field, and are not eligible for employer-sponsored health insurance.

policies

Active Duty Military Attestation

Active military duty personnel may be eligible to waive the Student Health Fee. Complete the attestation form and return it to Member Services.

Leave of Absence/Withdrawal

Students may apply for four months of additional coverage due to Leave of Absence or Withdrawl from the University. The additional coverage starts on the last day of student coverage, and important time restrictions apply.

Appeals for Additional Leave of Absence Coverage

Students on Leave of Absence from the University may appeal to extend coverage beyond the four months of Leave Of Absence coverage.

Pending Enrollment Waiver

Students who know that their alternate insurance coverage will start after the waiver deadline may complete a “Pending Enrollment” waiver by the deadline: July 31 (fall) or January 31 (spring). 

Waiver Rescind

Students who previously waived the Student Health Insurance Plan may be eligible to re-enroll based on certain criteria. 

November Degree

Student coverage ends depending upon the day the student completes degree requirements.

Medicare Certification

This form is for members to declare their eligibility for Medicare.

Cost Estimates

Checklist

Members can request a cost estimate if they meet eligibility guidelines and are currently enrolled in the health plan. An estimate does not guarantee coverage, and each admission, procedure, or service must be a medically necessary covered benefit and meet medical guidelines. All prior authorization and referrals must be obtained, if necessary.

There are two options for receiving an estimate of your financial responsibility for an upcoming service or procedure.
 

Estimates from Your Insurance Plan

Visit the Blue Cross Blue Shield of Massachusetts website and log into MYBLUE or call 1 (800) 257-8141 for assistance. To help get you started, use the Blue Cross Blue Shield checklist form, which provides guidelines on what information you need in order to receive an estimate. Once you are logged into MYBLUE, you can also:

  • View claims online

  • Monitor your deductible and out-of-pocket maximum

  • Request a written estimate

Estimates from Your Provider

All providers are now required to provide cost estimates for service they provide. Talk to your provider about obtaining an estimate prior to receiving care.