Welcome to the Employer's Section Company Information
BlueCross BlueShield of Texas Blue Card
 
         
     
 
What's New
Heart Failure Drug Digitek (digoxin) Recalled
Be Smart. Be Well.TM - a new wellness Web site
CDHP (BlueEdgeSM) Enrollment Surpasses 500,000 Milestone
Blue Medicare Private Fee-for-Service
Introducing BlueCare Dental ConnectionSM
BlueCare Connection® Adds Three New Programs
Complementary Alternative Medicine Discount Program
Medicine Safety Project
Blue Care Connection Member Communications
WalkingWorks
Keeping Health Care Affordable


Downloadable Forms

Please select one of the links below to view that form.

Form Name 

Form Number

PDF Size
Coverage Change Termination Form 
33 kb
Enrollment Application/ Change Form

TDI#:  EE/CHG3 1003

205 kb
Solicitud de Inscripción Grupal/Instrucciones para el Formulario de Cambio

TDI#:  EE/CHG3 1003

541 kb
Medical Claim Form

 

18 kb
Medical Claim Form - Spanish Version

 

72 kb
Dental Claim Form
137 kb
Dependent Addition and Change Form for Court Ordered Dependents 

TDI#:  GDA-CMHC-02

25 kb
Dependent Child Statement of Disability

TDI#:  DISABILITY02

19 kb
Small Group Employer Application
(rev 03/08)
 
For quotes entered after 04-12-08 for new accounts effective 07-01-08 and after.

TDI#:  SERA24

210 kb
Small Group Employer Application for Amendment (rev 03/08) 
For changes for new accounts entered after 04/12/08 for new accounts effective 07-01-08 and after.

TDI#:  SERA24A

160 kb
Small Group Employer Application (rev 03/07) 
For quotes entered after 05/15/07 for new account effective 7/1/07 and after

TDI#:  SERA23

325 kb
Small Group Employer Application for Amendment (rev 03/07) 
For quotes entered after 05/15/07 for new account effective 7/1/07 and after

TDI#:  SERA23A

248 kb
COBRA Initial Notice
Form #0009.443 (rev 08/04)
 
Employers are required to provide a COBRA Initial Notice when employees or their dependent spouses first become covered by a group health insurance plan subject to COBRA.

In an effort to assist employer groups, HCSC has incorporated this notice into the Certificates of Coverage and Benefit Booklet. Although HCSC has taken this extra step, it is the employer group’s responsibility to make this notice available to each covered employee and to the employee’s spouse (if covered under the health insurance plan) not later than the earlier of: Either 90 days from the date on which the covered employee or spouse first becomes covered under the plan; or if later, the date on which the plan first becomes subject to the continuation coverage requirements; or the date on which the administrator is required to furnish an election notice to the employee or to his or her spouse or dependent.
104 kb
Continuation of Coverage (COBRA) & COBRA Disability
Form #COBRA06, 05253.1106 (rev 11/06)

Application for Group Benefit Officers to request continued coverage for employee due to employee's reduction in work hours, retirement, termination, etc. Application includes two sections; Application For COBRA First Qualifying Event and Application for COBRA Second Qualifying Event.
106 kb
Group Administered 6 Mth Continuation Application
Form #GroupAdmin06, 43936.1106 (rev 11/06)

Note: If HCSC (Blue Cross Blue Shield of Texas) administers Texas State Continuation as a Third Party Administrator for your group do not use this form. Please call (888) 541-7107.
Application for Group Benefit Officers to request an additional 6 months of coverage after COBRA has expired or as an initial request for continued coverage for smaller groups not subject to COBRA regulations. 
90 kb
Dependent State Continuation
Form #StateContDep06, 43942.1106 (rev 11/06)
 
Existing Blue Cross and Blue Shield of Texas group members may request a continuation of coverage for up to 36 months from loss of coverage due to divorce, death or retirement of the employee.
38 kb


HR Forms
Form Name 

Form Number

PDF Size
Change Life/ Beneficiary

 

213 kb
Solicitud De Inscripcion De Grupo/ Cambio 

TDI#:  EE/CHG3 1003SP

546 kb
Student Dependent Certification 
32 kb


Medicare Secondary Payer Forms
Form Name 

Form Number

PDF Size
Instructions - Completing the Annual MSP Employer Acknowledgement Form 

TDI#:  21088.0207

59 kb
Annual MSP Employer Acknowledgement Form 

TDI#:  21084.0507

48 kb
Information Regarding the Medicare as Secondary Payer Statute 

TDI#:  21092.0207

64 kb

Under federal law, it is the employer's responsibility to inform its insurer or third-party administrator of proper employee counts for the purpose of determining payment priority between Medicare and another insurer. Employer size, not group health insurance plan size, is used in determining whether the group health insurance plan or Medicare is the primary payer. For more details please refer to the Instructions - Completing the Annual MSP Employer Acknowledgement Form. In the absence of employer-provided employee counts, the Center for Medicaid & Medicare Services (CMS) requires that the employer's group health insurance plan coverage be considered primary to Medicare. To comply with this requirement Blue Cross and Blue Shield of Texas requires employer groups to complete the Annual MSP Employer Acknowledgement Form on a yearly basis. Additional information regarding the MSP statute is available in the document titled Information Regarding the Medicare as Secondary Payer Statute.




A Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the
Blue Cross and Blue Shield Association.
© Copyright 2008. Health Care Service Corporation. All Rights Reserved.

Home | Important Information