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Claim Form

Usually, your health care provider will bill the insurance company directly for services provided to you or your covered dependents. If a provider bills you directly or requires payment at the time of service, you may submit a claim form for payment or reimbursement.

The Claim Packet you submit to BC Life and Health (administered by Blue Cross of California) must include the following:

Completed Claim Form

Completed Referral Form from the Student Health Center (students only).
Routine medical care outside the student health center requires a referral form from your student health center provider. If you receive treatment for a medical emergency, a referral is not necessary.

Itemized Bills
Itemized statements must be on the provider’s official letterhead and must include the following:

Patient’s name

Service date

Service rendered

Amount charged

Diagnosis for each service

Paid Receipts
If you have already paid for the service, include your receipt with a written request for BC Life and Health to reimburse you directly rather than pay the provider.

Please submit a claim packet each time you make a claim for payment or reimbursement.

MAIL THE COMPLETED CLAIM PACKET TO:

BC Life and Health (administered by Blue Cross of California)
USC Claims
P.O. Box 60007
Los Angeles, CA 90060-0007

For claim status information, call Blue Cross of California at (800) 888-2108.

You should keep a photocopy of each document in the Claim Packet for your records.

These forms are presented using Adobe Acrobat. You will need a copy of Acrobat in order to view or print these files. You can download Acrobat for free by choosing one of the methods below:

Download Acrobat from Adobe

Download Acrobat from ISD

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