New Refund Requests Form Available

Blue Cross Blue Shield of North Dakota (BCBSND) has a new form available for providers pertaining to unsolicited refunds.

Providers should continue to follow the standard claim correction and voids process as outlined in the provider manual, as necessary. Unsolicited refunds refer to refunds that were not requested by BCBSND. For example, if an adjustment request cannot be completed due to timeliness or the claim is purged from the BCBSND system, and a provider would like to return money to BCBSND to balance their patient’s account, this form can be utilized.

This form can be located in the Provider Forms and Documents section of our website under the Claims processing or by the attached link Unsolicited-Refunds-Form.pdf ( This form is intended to be used as a last resort to refund or return money to BCBSND for an overpayment, not in conjunction or solely for a claim adjustment/void.

Providers can:

  • Type within the form and then print it off and mail it with your check;


  • Print the form off and write the information on the form and mail it with your check. 

Please ensure the form is filled out in its entirety, the information is legible and accurate prior to mailing it with your check or it may be returned.

If you have any questions, contact the number on the back of the members ID card.