Forms

Member Forms

Coordination of Benefits Questionnaire
If you or your dependents are covered under more than one medical plan, the plans will work together to coordinate the benefits you receive. To determine if coordination of benefits is available and appropriate, Blue Cross and Blue Shield of Illinois may ask you to complete the coordination of benefits questionnaire.

Disabled Dependent
Use this form to certify disabled dependent status. To help ensure benefits are administered in accordance with your Boeing health care benefit plan, your plan requires annual recertification. Be sure to complete the disabled dependent form in its entirety, including the accompanying physician certification section on the second page.

Doula Claim Reimbursement Request Form
Use the doula claim reimbursement request form when you have expenses from a doula who did not bill the plan directly. Be sure the member and doula sections are completed to avoid a delay in processing your claim.

Essential Health Benefits Listing
This notice is being provided pursuant to the Illinois Consumer Coverage Disclosure Act and consists of a comparison between the Boeing-sponsored self-insured health plan options available to Illinois employees and the benefits deemed essential health benefits by the State of Illinois. If you have questions related to Boeing-sponsored health plan options, call Worklife at 1-866-473-2016 and when prompted say “health and insurance” then “other questions".

Medical Claim (Domestic)
Use this claim form to request reimbursement for applicable medical expenses incurred for services not directly billed to the plan.

Medical Claim Form (International)
Use this Blue Cross Blue Shield Global Core International medical claim form to request reimbursement for applicable medical expenses incurred internationally for services not directly billed to the plan.

Medical Travel Reimbursement Form
To provide consistent access to medical or behavioral health services for employees regardless of their home locations, Boeing has expanded its travel policy. Boeing, to the extent permitted by applicable laws, will pay for reasonable travel-related costs if any covered employee, spouse or domestic partner or dependent needs a covered medical service that is unavailable within 100 miles of the patient’s address. (Important benefit information: Benefit does not apply to covered pre 65 and post 65 retirees and dependents).

Prescription Drug Claim Form
Use this claim form to request reimbursement for applicable prescription drug expenses incurred for services not directly billed to the plan.

Standard Authorization to Use or Disclose Protected Health Information (PHI)
Complete and submit this form to allow the disclosure of your PHI to any specific person or entity.

Provider Forms

Applied Behavior Analysis (ABA) Clinical Service Request Form
This request will need to be completed for ongoing ABA sessions along with the member treatment schedule. This form is to be used after the initial form and initial visit have been completed.

Applied Behavior Analysis (ABA) Initial Assessment Request Form
This request will need to be completed for the first ABA session along with the member treatment schedule.

Electroconvulsive Therapy (ECT) Request
This request is for a clinical review if ECT meets the medical necessity definition under the member's benefit health plan.

Intensive Outpatient Program (IOP) Request
This request is for a clinical review if the IOP program treatment meets the medical necessity definition under the member's health benefit plan.

Predetermination Form
This request is for verification of benefits, prior to rendering services, that may be considered experimental, investigational, or cosmetic. Approvals and denials are based on approved medical policies.

Psychological/Neuropsychological Testing Request
This request is for a clinical review if psychological or neuropsychological testing meets the medical necessity definition under the member's benefit health plan.

Repetitive or Deep Transcranial Magnetic Stimulation
This request is for a clinical review if repetitive transcranial magnetic stimulation meets the medical necessity under the member's health benefit plan.