Blue KC - Submit a Claim

Patient Information – Who received care?

All fields in this section are required.

Patient Name

Blue KC Member ID

Medicare Advantage: Enter 00 in suffix field.

Blue KC Group ID

Patient Date of Birth
Use MM/DD/YYYY to format the birthday.

Relationship to Policyholder
- Self Spouse Child Life Partner Employee Other

Patient Gender
- Male
- Female
- Prefer not to answer

Policyholder Information

All fields in this section are required.

Policyholder Name
Street Address
City
State
ZIP Code

Healthcare Provider Information (Rendering Provider)

All fields in this section are required unless noted as optional.

Provider's Full Name
The name of the individual who rendered or delivered care.

Provider Tax ID
This is required. If you need help, ask your healthcare provider for their Tax ID.

Provider NPI
This is required. If you need help, ask your healthcare provider for their NPI number.

Provider NPI
To receive expedited processing, we encourage you to ask your healthcare provider for their NPI number.

Phone Number

Email Address
Optional

Street Address
Help with Medical Equipment or Lab Work Claims

For claims involving medical equipment:

For an online purchase, use the address your purchase was shipped to. Otherwise provide the address of the retail location or store where the purchase was made.

For claims involving lab work:

Use the address of the doctor or provider who ordered the lab work. For example, if your doctor ordered lab work, use the address of the office where they practice.
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Medical Equipment or Lab Work – Learn how to provide the correct address for medical equipment or lab work claims.

City

State

ZIP Code

Attach Itemized Receipt(s) from Your Healthcare Provider

Ask your provider for an itemized receipt, which provides proof of the care received. This document(s) is required and must include the following: provider name, the provider’s Tax ID, date(s) of service, the amount charged, a diagnosis code, a procedure code and the place of service. For your request to be honored, work with your provider to make sure all required information is included.

Attach document(s) from your provider:
The following file types are allowed: PDF, JPG, JPEG, DOC, DOCX, XLS, XLSX, PPT, RTF, TXT, or TIFF.
Press and hold the CTRL key to click and select multiple files to upload.

Describe the document(s) you are attaching

Claim Details

All fields in this section are required unless noted as optional.

Place of Service
Ambulance
Home Health Visit
Hospital Visit (inpatient)
Hospital Visit (outpatient)
Medical Equipment
Office Visit
Telehealth or Video Call
Urgent Care
Other

Describe the illness or injury for which the patient received care

Total Charges

Amount Paid By You

Additional Questions

Is the illness or injury connected to the patient's employment?

Date of illness, injury or Accident
Use MM/DD/YYY to format the date.

Does the patient have other group coverage?

Name of Insurance Company

ID Number

Group Number

Amount Paid by Other Insurance

Name of Insurance Company

ID Number

Group Number

Amount Paid by Other Insurance

Provide Your Email Address

An email address is required. We will email a copy to your inbox for your personal records.

Email address

If you experience issues submitting this form, please print and fax it to 816-278-1946.

Or mail to:

Blue Cross and Blue Shield of Kansas City
PO Box 419169
Kansas City, MO 64141-6169

Important: By continuing below, you agree that all information provided is accurate to the best of your knowledge. You understand that falsifying or misrepresenting essential information is a serious crime which could lead to fines or imprisonment.