There is no single BCBS Medicare reimbursement form. Blue Cross Blue Shield is a federation of more than 30 independent companies, and the right form depends on which plan you have: FEP Blue members use the Medicare Reimbursement Account (MRA) “Pay Me Back” Claim Form to recover Part B premiums, Medicare Advantage members use an out-of-pocket claim form issued by their specific BCBS affiliate, Medicare Supplement holders usually don’t file anything because Medicare forwards claims automatically, and care received abroad goes through BCBS Global Core or the federal CMS-1490S.
Which Form Matches Your Plan
Pull out your insurance card. The plan type printed on it tells you which process applies.
- FEP Blue Basic Option enrolled in Medicare Part A and Part B: the MRA “Pay Me Back” Claim Form, which reimburses your Medicare Part B premium payments up to $800 per calendar year.
- BCBS Medicare Advantage (Part C): your specific BCBS affiliate’s own out-of-pocket claim form. Log into the member portal on your card or call the number on the back to request the correct version for your regional plan.
- BCBS Medicare Supplement (Medigap): usually no form at all. Medicare forwards your claims to your supplement plan automatically.
- Care received outside the U.S. under BCBS Global Core: the Global Core eClaim upload or paper claim form from the Global Core member portal.
If a domestic provider simply refused to bill Medicare, you may instead need the CMS-1490S, the federal patient request form for submitting claims directly to Original Medicare. It’s available on the CMS website and gets mailed to your regional Medicare Administrative Contractor.
FEP Blue MRA Pay Me Back Form
This is the form most people are searching for. Its purpose is narrow: reimbursing the Medicare Part B premiums you pay out of pocket. FEP Blue Basic Option members enrolled in both Part A and Part B can receive up to $800 per calendar year.
What You Need to Prove
The IRS requires five pieces of information on your supporting documents: the date you paid the premium, the provider name (Medicare, in this case), a detailed description of the expense, proof of payment, and your name. Acceptable proof of payment includes a Social Security Cost-of-Living Adjustment (COLA) statement, a canceled check, a credit card statement, or a bank statement. If you submit a check, credit card, or bank statement, you also need to attach a Medicare Part B premium bill that matches the amount paid.
How to Submit
- Online or mobile: log in at fepblue.org/mra or use the EZ Receipts app (App Store and Google Play) to upload your proof of payment.
- Mail: download the MRA Pay Me Back Claim Form at fepblue.org/mra, attach copies of your receipts, and send everything to P.O. Box 14053, Lexington, KY 40512.
- Fax: (877) 353-9236.
The filing deadline is December 31 of the year following the benefit year. Premiums paid during 2025 must be filed by December 31, 2026.
Medicare Advantage Out-of-Pocket Claims
If you paid for a covered service directly because the provider didn’t accept your plan, you were in an emergency, or you saw an out-of-network provider, you file with your BCBS affiliate. The exact form varies by company. Check your affiliate’s member portal or call the customer service number on your card to request the correct version.
Every affiliate asks for the same core information: your member ID number, the provider’s name and contact information, the provider’s National Provider Identifier (NPI, a unique 10-digit number assigned under HIPAA), the date of service, a diagnosis or reason for treatment, and an itemized bill that lists each service and its charge separately. A summary receipt won’t work. You also need proof that you already paid: a canceled check, credit card statement, or signed provider receipt.
Keep copies of everything you send.
Medicare Supplement: When You Actually Have to File
Most BCBS Medicare Supplement policyholders rarely file a reimbursement form. When your doctor bills Original Medicare, Medicare processes the claim first and then automatically forwards it to your Medigap insurer through the Coordination of Benefits Agreement (COBA) crossover process. Virtually all standard Medigap plans participate.
Manual filing becomes necessary only in a few situations: the crossover fails and your Medigap plan never sends an Explanation of Benefits for a service Medicare already paid; you received care from a provider who didn’t bill Medicare; or you received care abroad. Call the customer service number on your BCBS Supplement card, and they’ll direct you to the correct form and mailing address for your specific plan.
Care Received Outside the U.S.
Foreign hospitals and providers aren’t required to file Medicare claims, so you’ll generally file yourself. With Original Medicare, use the CMS-1490S. It’s fillable online: complete it on your computer, print it, and mail it with your itemized bills to the appropriate Medicare Administrative Contractor.
With BCBS Global Core coverage, use their separate system instead. The member portal and mobile app both offer an eClaim upload. You can also download a paper form from the portal, complete it, and upload a photograph or scan. Global Core requires the reason for treatment or diagnosis, an itemized bill, dates of treatment, the provider’s name and contact information, and your preferred reimbursement method (check, bank wire, or ACH). Claims through Global Core must be submitted within 18 months of the date of service.
Documentation to Gather Before You Start
Whichever form you’re filling out, the documentation overlaps heavily. Pull all of this together first:
- Your insurance card, for the member ID number and plan information.
- An itemized bill. Not a balance-due statement or payment summary. The bill must list each service separately with its own charge, date, and description.
- Provider details: full name, address, phone number, and NPI. If you don’t have the NPI, look it up free in the NPPES registry at npiregistry.cms.hhs.gov.
- Proof of payment: canceled check, credit card statement showing the charge, bank statement, or a signed receipt from the provider’s billing office.
- Diagnosis information. Some forms ask for ICD-10 diagnosis codes or CPT procedure codes; if you don’t have them, your provider’s billing office can supply them.
Organize your documents in date-of-service order before you start filling in the form. Each entry on the form should correspond to a specific line item on your itemized bill. That one-to-one match is what reviewers check first, and mismatches are one of the fastest ways to trigger a delay.
Filing Deadlines by Plan Type
Missing a filing deadline means your claim gets denied with no opportunity to appeal.
- Original Medicare (CMS-1490S): within 12 months of the date of service. If the last day falls on a weekend or federal holiday, the claim is timely if filed the next business day.
- BCBS Medicare Advantage: plans set their own limits, commonly 90 to 180 days depending on the insurer. Check your Evidence of Coverage or call member services for the exact deadline.
- FEP Blue MRA: December 31 of the year following the benefit year.
- BCBS Global Core: 18 months from the date of service.
Claims denied for missing the Original Medicare 12-month deadline are not eligible for redetermination, which is the first level of appeal. The denial is final. Medicare Advantage late-filing denials follow the plan’s internal grievance process, a separate and narrower path than a standard claim appeal.
If Your Claim Is Denied
The denial letter is your roadmap. It states the reason, the deadline to appeal, and where to send the appeal. Because BCBS is a federation of independent companies, the specific appeal form and submission address vary by affiliate, and using the wrong one adds weeks of delay.
For BCBS Medicare Advantage denials, you have 60 calendar days from the date on the denial notice to request a Level 1 reconsideration. Standard appeals are typically processed within 30 days. If a delay could seriously harm your health, you can request an expedited appeal, which must be decided within 72 hours. Include the denial letter, any additional medical records or documentation supporting why the service was necessary, and the claim number from the original submission.