Massachusetts Claim Form PDF Details

Are you a Massachusetts resident who's been trying to file a claim in the state, but don't know where to start? If so, you're not alone! A common complication of filing claims in any state is understanding all of the paperwork. But when it comes to Massachusetts, things can be made easier with today's blog post. Here we'll provide an overview about the process for submitting the required claim form for your particular matter - providing clear instructions and resources along the way. So jump in and discover how easy it can be getting started on that important Massachusetts-based claim form!

Form NameMassachusetts Claim Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namessubscriber claim, blue cross shield massachusetts form, massachusetts ma claim, blue cross shield claim

Form Preview Example


Instructions for Submitting Claims

1.Submit a claim only when you are billed for services from a provider that does not directly submit a claim to the local Blue Cross Blue Shield plan.

2.Submit a separate form for each patient.

3.Attach an original itemized bill from your provider (required information & example on the back)

4.Keep a copy of all bills and claim forms submitted (originals will not be returned)

5.Be sure to sign and date the completed form.

6.Mail claim form and all attachments to BCBSMA, P.O. Box 986030, Boston, MA 02298

Subscriber Information

Identification Number (including alpha prefix)

Last Name

First Name

Middle Initial

Address-Number & Street



Zip Code

Date of Birth (MM/DD/YY)

Employer’s Name

Patient Information

Patient Last Name

First Name

Middle Initial

Date of Birth (MM/DD/YY)




Patient is:

q Subscriber (contract holder) q Student (age 19 or older) q Other (specify)

q Spouse (to contract holder)q Child (age 18 or younger) q Handicapped Dependent (age 19 or older)

Does the patient have other insurance: q Yes q No



Effective Date:

Medicare Part A (Hospital)

q Yes q No ____/____/_____

Medicare Part B (Medical)

q Yes q No ____/____/_____

Medicare Part D (Pharmacy)

q Yes q No ____/____/_____

Other Blue Cross



Blue Shield Membership?

q Yes q No ____/____/_____

Other Insurance Plan?

q Yes q No ____/____/_____

Identification Number:




Name and address of other insurance:

Was treatment for:

Accident at work? q Yes q No

Date of accident ____/____/_____

Auto accident? q Yes q No

Date of accident ____/____/_____

If yes, name of auto insurance:

Policy Number:

Other accident? q Yes q No

Date of accident ____/____/_____

Subscriber Signature:


Please allow up to 30 days for your claim to process.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association.

Example of a Complete Itemized Bill


Smith Speech Center

















123 Main St.






















Boston, MA 12345







































To: Joe Smith
























Patient Name: Joan Smith






15 Elm St.




















Referring Doctor: Dr. John Jones





Anytown, MA 12345




























































Jane Johnson,





Tax ID/NPI: 99-9999999















Speech-Language Pathologist














License # Y777777







































































Procedure Code(s)






Procedure Description



Date of Service













Speech–Language Therapy


















































Speech–Language Therapy







































Diagnosis Codes: 784.50, 315.31









Total: $290.00










































Payments: $290.00









































Balance Due: $0.00























Please note that your bill does not need to look exactly like the example above, but MUST contain the following required information:

1.A letterhead from the provider that MUST include all of the following:

Provider name

Provider address

Provider Tax ID/NPI

Provider credentials, i.e., the initials associated with the educational degrees the provider has earned. Examples include: MD, LICSW, DC, PT, OT, ST

2.Patient’s name

3.Date(s) of service

4.Itemized charges for each date of service and type of service received

5.Procedure codes (HCPCS/Revenue codes) for all services received

6.Diagnosis code(s) for services received

7.Number of Units-this is the number of times a service was performed on a particular date of service. This is required for occupational, physical & speech therapies, anesthesia and chiropractic services.

8.Attach any related claim summaries or Explanation of Medicare Benefit Forms you may have received for these services, including those received from other insurance companies.

9.When submitting a claim for PRESCRIPTION DRUGS, you must submit an itemized receipt from your pharmacy that includes:

National Drug Code (NDC)

Name of drug

Date dispensed

Quantity dispensed

Name of prescribing physician

To view processed claims, visit our website If you have not already registered for Member Central, click Create an Account and follow the directions.

®Registered Marks of the Blue Cross and Blue Shield Association. © 2010 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.


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