Making Claims

This section describes the claims process for each benefit. It also explains how you can coordinate health and dental benefit payments with your spouse's/partner's plan.

Health Claims

All eligible extended health claims must be submitted to the Insurer by June 30 or December 31 (depending on your policy) of the calendar year following the calendar year in which the individual incurred the expense.

If your employment terminates with your BCCA employer, or you are no longer eligible for coverage under the BCCA Employee Benefit Program, you must submit all claims incurred before the termination within 90 days after you leave or after you are no longer eligible for coverage.

Submitting claims by mail

To submit eligible extended health claims by mail, for Pacific Blue Cross groups print and complete the Extended Health Care Standard Claim Form (10-60-20) (PDF). For Nexus (National) Blue Cross groups print and complete the Nexus National Claim Form (PDF).

• Ensure that all information on the form is complete and clearly legible.
  
  
• Incomplete or missing information will delay the processing of your claim.
  
  
• Sign and date the form.
  
  
• Attach all receipts, or photocopies of receipts if accompanied by an explanation of benefit from another carrier, to the form. Claims cannot be considered or paid without supporting receipts. Keep copies of your receipts and form for income tax and other purposes.
  
  
• Provide explanation or proof to support the claim, such as itemized bills, attending Physician's statement, or any other information PBC considers necessary.
  
  
• Mail the completed form to Pacific Blue Cross or for Nexus groups, your provincial Blue Cross claims centre (address on claim form).
  

Pacific Blue Cross (PBC)/Blue Cross will mail the cheque for your eligible expenses directly to your home.

For questions concerning the status of claims, for Pacific Blue Cross groups, you can either contact PBC's Call Centre directly at (604) 419-2600 for EHC claims or toll free 1-888-275-4672. Nexus (National) Blue Cross groups can call toll-free 1-888-873-9200. You can also view the status of your claims by accessing the PBC CARESnet website. To read more about PBC CARESnet, see the section on this site about this service.

Prescription Drugs

Most BCCA plans require paper claim submission for prescription drug expenses. In this case, you pay for the cost of the prescription drug, then complete Pacific Blue Cross's Extended Health Care Standard Claim Form (PDF) or (for Nexus groups), the National Blue Cross Claim Form (PDF) and forward it to the insurer with the original receipt(s) attached (as per the instructions above).

If your plan includes a "pay-direct drug card", reimbursement will not be necessary in most cases, as transactions will occur at the point of sale (i.e., at a pharmacy).

If, for any reason, you have a pay-direct drug card and it was not used at the point of sale, simply complete Pacific Blue Cross's Extended Health Care Standard Claim Form (PDF), or for Nexus groups, the National Blue Cross Claim Form (PDF) and attach the original receipt(s). You may submit claims directly to Pacific Blue Cross/Blue Cross.

Medical Travel Benefit (MTB)

To submit an eligible MTB claim, print and complete the MTB Claim Form (PDF). A pre-authorization is recommended for MTB claims to ensure that the submitted expenses are eligible.

• Ensure that all information on the form is complete and clearly legible.
  
  
• The referring physician must complete part A of the form.
  
  
• You should complete Parts B and C, as applicable. Sign and date the form.
  
  
• Attach all original receipts. Claims cannot be considered or paid without supporting receipts. Keep copies of your receipts and form for income tax and other purposes.
  
  
• Incomplete or missing information will delay the processing of your claim.

Mail the completed form to the address noted on the top right hand corner of the form. Pacific Blue Cross (PBC)/Blue Cross will mail the cheque for your eligible expenses directly to your home.

Out-of-Country Claims

For Pacific Blue Cross Groups

You must complete an Emergency Out-of-Province Claim form (PDF) and forward it to Pacific Blue Cross with attached itemized bills outlining the services for which they were charged.

Pacific Blue Cross will coordinate the claim with the Medical Services Plan of British Columbia directly on your behalf. This process is explained on the first page of the claim form.

• Claims should be made promptly as the MSP claiming deadline is 90 days from the date of service.
  
  
• The Members Statement and Patient's/Guardian's Authorization for Release of Information must be signed in the space provided regardless of whether you or your dependent(s) incurred the expense.
  
  
• If your spouse incurred the expense, both you and your spouse must sign in the spaces provided.
  
  
• If you incurred the expense, you must sign both "Member's signature" and "Patient's signature" or "Parent/guardian" if the patient is a minor.
  
  

For National (Nexus) Blue Cross Groups

To submit an out-of-country claim, call the Toll free number on the back of your National (Nexus) Blue Cross ID card. You will reach your local Blue Cross office, who can assist you by sending out an Out of Country claim form specific to your province of residence.

For All Groups

Please note that in the event of a medical emergency while out-of-country, you should contact the travel assistance provider, Medi-Assist immediately to arrange payment. For any trips out-of-country, even of short duration, please ensure to carry your Medi-Assist card with you and your Pacific Blue Cross ID card, so this information is easily accessible.

The customer service representatives at Medi-Assist can help co-ordinate the coverage options.

Dental Claims

You must submit all eligible dental claims to Pacific Blue Cross or National Blue Cross (for Nexus groups) within 90 days of the completion date of services. Failure to submit a claim within the 90 day limit will not invalidate the claim if it is submitted as soon as reasonably possible. In no event will PBC/Blue Cross pay any claim or adjustment submitted later than 1 year from the date the expense was incurred.

An expense is incurred on the date the dentist performs a single appointment procedure. For procedures that take more than one appointment, the employees incur the expense until the entire procedure is completed. You may be required to provide the dentist's statement of the treatment received, pre-treatment x-rays and any additional information considered necessary by PBC/Blue Cross.

If your employment terminates with your BCCA employer, or you are no longer eligible for coverage under the BCCA Employee Benefit Program, all claims incurred by you before your termination must be submitted within 90 days after you leave or are no longer eligible for coverage.

Submitting dental claims electronically

Your dentist may be able to send claims electronically to the Insurer, which can facilitate payment for dental claims directly between PBC/Blue Cross and your dentist. You should discuss this option with your dentist.

Submitting dental claims by mail

To submit eligible dental claims by mail, print the Dental Claim form (20-70-201) (PDF) (the standard dental claim form supplied by the dentist can also be used) or for Nexus groups, the National Blue Cross claim form (PDF). On the standard dental claim form, the dentist must complete Part 1 and you must complete Part 2.

• Sign and date the form. Mail the completed form to Pacific Blue Cross or for Nexus groups, your provincial Blue Cross claims centre (address on claim form).
  
  
• Pacific Blue Cross/Blue Cross will mail the cheque for your eligible expenses directly to your home.

For questions concerning the status of claims, you can either contact PBC's Call Centre directly at (604) 419-2300 for dental claims or toll free 1-888-275-4672. Nexus (National) Blue Cross groups can call toll-free 1-888-873-9200. You can also view the status of your claims by accessing the PBC CARESnet website. To read more about PBC CARESnet, see the section on this site about this service.

Pre-authorization for Extended Health and Dental Care Claims

For any extensive course of treatment involving crowns, bridgework, etc., which may exceed $300, we recommend you ask your dentist to complete a cost estimate before the work is completed. Have your dentist send the estimate to Pacific Blue Cross/Blue Cross's claim department to determine how the expenses will be reimbursed. Pre-authorization is also required for any Extended health care durable medical supply expense exceeding $5,000.

PBC CARESnet

CARESnet provides Pacific Blue Cross members with secure online access to benefits information 24 hours a day. Pacific Blue Cross recently enhanced CARESnet to include access to dental information. Now, in addition to giving members access to their health information, you can also access information on your dental plans and claims.

More and more members rely on CARESnet to access information about their Blue Cross benefit plans. We encourage all Pacific Blue Cross and BCCA benefit plan members to register for CARESnet. To register for CARESnet or to take an online tour, click here. If you have any questions or require more information, contact Pacific Blue Cross.

Disability Claims

If you become disabled and are unable to perform the duties of your own occupation, you should apply for Long Term Disability and Life Waiver of Premium. If your BCCA employer plan includes Short Term Disability coverage, you should apply for this benefit immediately. If your plan does not include this benefit, you should contact your local Employment Insurance office to inquire and apply for EI Disability benefits.

Note that provided you qualify for Long Term Disability benefits, benefit payments will not begin until the Elimination Period (waiting period) under your particular plan has been satisfied.

For all claims of this nature, please contact your Benefits Administrator at your place of employment as soon as possible. Instructions will be provided at that time, including the necessary claim forms which will require completion.

Claim Form Completion

1. Long Term Disability, Life Waiver of Premium and Short Term Disability are both underwritten by Great-West Life (GWL). Claims are submitted using forms:

   Short Term Disability

   • GWL Short Term Disability Employer's Statement
   • GWL Short Term Disability Claim Form

   Long Term Disability

   • GWL Long Term Disability Employer's Statement
   • GWL Long Term Disability Claim Form
   
   
   

   If your plan includes both Short and Long Term Disability benefits with the BCCA Employee Benefit Program, then the two separate Employer's Statements noted above are not required. Instead, the employer should complete the following form to accompany the initial Short Term Disability Claim Form:
   
   

   • GWL STD & LTD Job Description Form

    

2. Once all sections of the above forms are completed by the appropriate individuals, the original forms should be forwarded to your Benefits Administrator. Your Benefits Administrator will forward these forms to the BCCA Employee Benefit Program office along with a copy of your last pay stub. The BCCA Employee Benefit Program office will then forward them to the insurer for processing.

   Note: to maintain confidentiality of medical information, please return any forms with medically related information to your Benefits Administrator in a sealed envelope. Your Benefits Administrator/Employer does not have to see this information.

3. Claims must be submitted six to eight weeks before the end of the Elimination Period (for Long Term Disability) and as soon as possible after the date of disability for Short Term Disability claims (refer to your benefit summary for the applicable elimination periods for both Long and Short Term Disability benefits).

   Upon your return to work after a disability, your Benefits Administrator will inform the BCCA Employee Benefit Program office by completing the following form:
   
   

   • GWL Notice of Return to Work (PDF)
   
   The BCCA Employee Benefit Program office will forward this form to the insurer on your behalf.

If you are eligible for Worker's Compensation (WCB) Benefits, you will receive a Worker's Compensation claim form from your physician. However, you should still apply for Long Term Disability benefits as well as Life Waiver of Premium. WCB disability benefits are typically higher than what you would receive through your LTD plan and are deducted from any disability benefit you may become eligible for. However, although you may not receive payment now, if you stop receiving benefits from WCB and are still deemed to be disabled, you may still be able to claim for LTD benefits in the future. As well, the benefit premiums would be waived during the disability period if you qualify for waiver of premium. Please contact your Benefits Administrator in these situations.

Continuation of Extended Health and Dental Care benefits While Disabled

Please note that under the BCCA Employee Benefit Program, at the employer's request, EHC and Dental coverage can continue for one year from the date of approval for LTD benefits for disabled employees provided premiums continue to be paid. After this one year period, the disabled employee has 60 days to convert their EHC/Dental coverage to an individual plan if they wish. Information regarding conversion of EHC/Dental benefits is provided under the Converting Benefits for Extended Health and Dental Care section of this site. Under no circumstances will EHC/Dental coverage continue for more than 1 year from the date of approval for LTD benefits.

For Short Term Disability and Long Term Disability Claims Inquiries, contact Great-West Life at:

Great-West Life 300-1075 West Georgia Street Vancouver, BC V6E 3C9 Phone: (604) 646-1200 Website: www.gwl.ca

Life Claims

In the event of accidental injury or death, you or your Beneficiary should contact your plan's Benefits Administrator as soon as possible, who will then contact the BCCA Employee Benefit Program office. Instructions will be provided at that time, including the necessary claim forms which will require completion.

Claim Form Completion

1. The employer and claimant must complete the applicable sections of the following Great-West Life forms:

   Employee Life, Dependent Life and Optional Life Claims

   • Group Life Claim Report
   
   
   
2. The insurer will also require the following documents:
   
   
   • Proof of Death - Original Provincial Death Certificate (or certified copy) or Funeral Director's Statement of Death. If neither of these forms is available, then the following form is required:
     
     
     • Attending Physician's Certificate of Death
   
   
   
3. Once all sections of the above forms are completed by the appropriate individuals, the original forms and supporting documents should be forwarded to your Benefits Administrator. Your Benefits Administrator will forward these forms to the BCCA Employee Benefit Program office who will then forward them to the insurer for processing.

AD&D or Voluntary AD&D Insurance Claims

In the event of accidental injury or death, you or your Beneficiary should contact your plan's Benefits Administrator as soon as possible, who should then contact the BCCA Employee Benefit Program office. Instructions will be provided at that time, including the necessary claim forms which will require completion.

Claim Form Completion:

1. For accidental death claims (basic or voluntary coverage) the physician, employer and claimant must complete the applicable sections of the following Industrial Alliance Pacific forms:
   
   
   • Proofs of Death - Physician's Statement (8223E/F)
   • Certificate of Employer (8220)
   • Claimant's Statement (8222)
   
   
   
2. The insurer will also require the following documents:
   
   
   • Proof of Death - Original Provincial Death Certificate (or certified copy).
   • Newspaper clipping, if available (for AD&D claims)
   • Police Report (for AD&D claims)
   
   
   
3. Once all sections of the above forms are completed by the appropriate individuals, the original forms and supporting documents should be forwarded to your Benefits Administrator. Your Benefits Administrator will forward these forms to the BCCA Employee Benefit Program office who will then forward them to the insurer for processing. Please note that in some cases the insurer may request a toxicology or autopsy report to verify the cause of death.

Beneficiary Designation

It's important to note that along with the above forms, the BCCA Employee Benefit Program office will include your original enrollment card and any beneficiary change forms for Life claims and a copy of your enrollment card/change forms for Dependent Life/AD&D/Optional Life claims. Because of this, it is important to ensure your beneficiary designation is up-to-date.

Coordination of Benefits

You may be able to coordinate your benefits if your spouse also has coverage under another employer's health and/or dental care plan. This means that as long as your spouse has couple or family coverage, you can submit claims to your spouse's benefit plan (and vice versa). If one plan does not refund 100% of the expenses, the other plan will refund the difference, subject to the plan limits.

For example, if you have a dental claim for $100, and your dental coverage covers 80% of the cost of eligible dental expenses, you will be reimbursed for $80. If your Spouse has couple or family coverage under his or her plan, you can submit a claim to your spouse's plan for the remaining $20.

There are some rules about coordinating health and/or dental benefits:

• To coordinate benefits with a spouse, you both must be covered under an employer's health and/or dental care plan. At least one of you must have couple or family coverage.
  
  
• You or your spouse can never receive a refund of more than 100% of eligible expenses.
  
  
• You must always submit claims for expenses incurred for yourself to the BCCA Employee Benefit Program first. Make sure photocopies of your receipts are kept. If the refund is less than 100% of the cost, you can then submit a claim for the difference to your spouse's plan.
  
  
• Your spouse must always submit claims for expenses incurred for himself or herself to his or her own plan first. If your spouse's refund is less than 100% of the expense, then he/she can submit a claim for the difference to the BCCA Employee Benefit Program.
  
  
• Claims for dependent children must go first to the plan of the parent whose birthday comes first in the calendar year. If you and your spouse have the same birthday, submit the children's claims to the plan of the parent whose first name comes first in the alphabet. If you and your spouse are separated or divorced, the child's claim must go first to the plan of the parent who has custody of the child.

You will receive an explanation of benefits from the first Insurer that processes the claim. This statement must be attached to the second claim form. You should also attach copies of their receipts.