Benefits Forms: Claim Forms
IMPORTANT: All of the forms listed on these pages are in Adobe
Portable Document Format (PDF). If you do not already
have Adobe Acrobat Reader on your computer, you must download
and install Adobe
Acrobat Reader before you will be able to view
or print Benefits forms.
Dental Plan Claim Form
- MetLife Dental Expense Claim Form (for services received through 12/31/08)
- Delta Dental Claim Form (for services received on or after 1/1/09)
Medical Plan Claim Forms
- BCBSM Community Blue PPO Plan Claim Form (Domestic claims)
- BCBSM CMM Plan Claim Form (Domestic claims)
- BlueCard Worldwide International Claim Form (Foreign Claim)
- GradCare Member Reimbursement Form
- Health Alliance Plan (HAP) HMO
As a general rule, HAP members should not receive bills from affiliated physicians for covered services received in network. However, HMO members should expect to receive bills for services received from out-of-network providers. If a member receives a bill that they feel should be HAP's responsibility, they should contact the HAP Client Services department for assistance or send a copy of the itemized bill, their HAP ID number, and receipts for payment to:
HAP
Claims Department
2850 W. Grand Boulevard
Detroit, MI 48202
Members will receive an Explanation of Benefits (EOB) for claims processed that may include an out-of-pocket responsibility.
- Priority Health Claim Form
- U-M Premier Care Member Reimbursement Form
Prescription Drug Plan Claim Forms
- Prescription Drug Reimbursement Form (SXC)
- Prescription Drug Reimbursement Form — Foreign Claims (SXC)
For prescriptions purchased outside the United States. - Prescription Drug Reimbursement Form — Compound Prescription Only (SXC)
Vision Plan Claim Form
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Benefits Office reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.