CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

Most common forms

If you can't find the form you need here, you can log in to the employer portal or contact a member of your Blue Team.

Employee Change Form

Submit form to cancel coverage or change employee name or address.

 

Employee Change Form

Assist an employee file a claim for medical services.

Billing and payments

Electronic Funds Transfer (EFT) Authorization Agreement

Complete bank information and attach a copy of a cancelled or voided check to verify account and routing/transit numbers. Payment withdrawals from your bank account will be completed on the 1st of the month. Billing schedule is subject to change due to holidays and weekends.

Eligibility and renewals

2019 Medical Loss Ratio (MLR) Form - To be completed for 2020 group

Submit the MLR form, as required by the Affordable Care Act (ACA).

 

Employee Change Form

Submit this form to cancel an employee's coverage, change an employee's address or update an employee's name. You may also be able to complete this change online faster and easier within the Employer Portal.

 

Health Affiliation and OOA Waiver

If you offer a health plan that requires the selection of a specific network, use this form to:

  • Choose a network
  • Change network at renewal, or one other time in the year
  • Put a waiver on a covered family member who may reside outside the network service area