Blue Cross and Blue Shield of Montana

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Provider Claim Forms

You may print and complete the following forms.

You may fax them to 406-791-4119, or mail them to:

Blue Cross Blue Shield of Montana
PO Box 5004
Great Falls, MT 59403-5004

Claims Forms

Professional providers should complete the CMS-1500 PDF 22kb claim form to request compensation for medical services. Print and use this form in color so our optical character recognition scanner can read your claim.

Ex¹² users click here.

Hospitals and facilities should complete the UB-04 PDF 102kb claim form to request compensation for medical services. Print and use this form in color so our optical character recognition scanner can read your claim.

Dental providers may use the BCBSMT Dental Claim Form PDF 66kb to request compensation for medical services.

The BCBSMT Provider Manual will assist your medical practice with submitting claims and understanding the payment process.

Referral Forms

The Referral for Specialty Care PDF 31kb form is required for members of Blue Select and HMO style plans only. Refer to the BCBSMT Participating Provider Manual, Managed Care chapter, for referral procedures.

Four-part paper forms can be ordered by calling Customer Service at 1-800-447-7828. Provide a copy of the completed referral form to BCBSMT (FAX 1.406.791.4119), the specialist, and the patient, and retain a copy for the patient's chart.

Blue Cross and Blue Shield of Montana serves the residents and businesses of Montana.
® Registered Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.