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Claims related to accidental injuries

When a member is injured in an auto accident or on the job, another insurer is often primary. The guidelines below will help you submit these coordination of benefit claims.

Reminder: Third-party liability claims, like other claims requiring attachments, must be mailed. Submit original claim forms. We cannot accept faxes and photocopies for processing.

If you’re submitting a claim for a member who has related: You can bill us for any outstanding balance after: Be sure to:
Auto insurance The auto insurer:
  • Pays the first $2,000 or the entire Personal Injury Protection (PIP) if applicable* and any additional auto insurance Medical Payment (MedPay) coverage available.
  • Denies the claim because of a PIP benefit exclusion
  1. Complete the appropriate item on a red paper claim form.
  2. Attach the PIP exhausted letter to your initial claim and to any subsequent claims that are related to the motor vehicle accident.
  3. Mail claims to the appropriate address.
Workers’ compensation insurance The workers’ compensation insurer has:
  • Denied your claim for services (that is, the services were unrelated to the workers’ compensation injury)
  • Denied liability for our member’s illness or services as not being related to an accident injury (that is, there was no compensable workers’ compensation injury)
  1. Complete the appropriate item on a red paper claim form.
  2. Attach a denial to the first and subsequent claims you submit related to the denied illness/injury.
  3. Mail claims to the appropriate address.

* Other states’ Blue Cross Blue Shield Plans may have other Personal Injury Protection (PIP) dollar limits.

Notes:

  • If a third-party or lump-sum settlement is reached prior to claim submission, claims may not be honored.
  • Workers’ compensation insurers’ denials are subject to review by the Third-Party Liability Department to determine if claims will be honored.
  • Exemptions from state law:
    • Self-funded accounts
      • Blue Cross has the right to cite exemption from state law for self-funded accounts under the Employee Retirement Income Security Act (ERISA).
      • If the account is self-funded, ERISA may pre-empt state insurance law.
      • The PIP insurer will not be able to rely on standard coordination of benefits.
      • Self-funded accounts process secondary to all automobile PIP and MedPay coverage.
    • Federal Employee Program (FEP)
      • Blue Cross also has the right to cite exemption from state law for FEP members because FEP is governed under the Federal government’s Office of Personnel Management.
      • The contract allows FEP to process secondary to all automobile PIP and MedPay coverage.
      • If a third-party or lump-sum settlement is reached prior to claims submission, claims may not be honored.

If you have questions about billing claims related to other types of accidental injury (for example, dog bites or falls), please contact our Third-Party Liability Department at 1-800-444-6502.

How to appeal a third-party liability claim involving a Massachusetts member

If we reject your claim because of an error in the claim, follow the replacement claim process. However, if your third-party liability claim involves a Massachusetts member and you disagree with the third-party liability denial, fax a Request for Claim Review Form and any required documents to our Third-Party Liability Department at 1-617-246-9967.

BlueCard (out-of-state) third-party liability appeals should be mailed to the claims address for Professional or Institutional claims.

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