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HRA Health Care Claim Form 

HRA reimbursement requests can be made using the applicable claim form above, although with the automated reimbursement, manual claim submission should be minimal.

Simply complete and sign the claim form and attach one of the following:

• Your Explanation of Benefits from BlueCross BlueShield of Tennessee, or
• Receipts for prescriptions, health-related expenses or dependent care expenses.

Completed reimbursement requests should be mailed or faxed to:

Mail:

BlueCross BlueShield of Tennessee
Claims Service Center
PO Box 180207-7207
Chattanooga, TN 37401-7207

Fax:
1-888-666-1221

Because these benefits are optional, please check your Evidence of Coverage or your employer’s summary plan description to make sure you have a BlueCross BlueShield of Tennessee HRA.