View the forms, plan documents and resources you need to manage your U-M health plan benefits. Access Summary of Benefits and Coverage (SBC) documents, provider directories, enrollment and change forms, claim forms, and other health plan resources.
Most enrollment and/or benefit changes are completed in Wolverine Access. However, certain changes may be completed by submitting a downloadable form.
Benefits Enrollment/Change Form for Benefits-Eligible Fellowship or Medical Students (STV)
Group Health Insurance Application for Special Enrollment (HIPAA)
Additional forms for dental, life insurance, prescription drug, COBRA insurance and more plans are available on the Benefit Plan Forms and Documents page.
The Affordable Care Act requires large employers like the university to report Social Security numbers for individuals and their covered dependents on Form 1095, a tax form that reports information about health coverage. If you received a notice from the university because a Social Security number is not on file for one or more of your dependents covered by your University of Michigan health plan, please complete the Dependent Information Form Upload eForm.
IMPORTANT INFORMATION: The federal Mandatory Insurer Reporting Law requires group health plans to report to Medicare the Social Security numbers of adults covered under a group health plan. To comply with this law, you will be asked to provide this information for your spouse or OQA. If your spouse or OQA is not eligible for a Social Security number, you will be asked to provide the reason. Under the Affordable Care Act, the university is also required to request the Social Security number of each person enrolled under a U-M health plan, including children. If you do not provide your dependents’ Social Security numbers at the time of enrollment, you may receive requests from U-M to allow the university to comply with federal legislation.
Use these forms to submit a claim to your health plan.
BCBSM Reimbursement/Claim Form for Community Blue PPO, CMM and CDHP plans
BCN Reimbursement/Claim Form for U-M Premier Care and GradCare
Blue Cross Blue Shield International Claim Form (foreign claims) - Download, complete and mail the claim form, or file an eClaim online.
To file an eClaim:
Go to the Blue Cross Blue Shield Global Core website.
Click to accept the terms and conditions.
Enter the three letters of your "Enrollee ID" found on your Blue Cross Blue Shield member ID card, and then click Go.
Select Claims on the menu bar.
To file a Blue Cross Blue Shield Global Core eClaim online, log in with your username and password or register for access.
Information about your benefits in retirement.
The resources below pertain to COBRA continuation of your benefits.
Use these Summary of Benefits Coverage (SBC) documents for quick reference about your health plan coverage or to easily compare your health plan options.
View the Uniform Glossary of Health Coverage and Medical Terms document for help understanding the information included in the Summary of Benefits and Coverage (SBC) documents.
H.R. 2471, the Consolidated Appropriations Act, 2022 introduced new federal regulations for health-care price transparency. It aims to assist consumers by increasing the availability and transparency of health-care price information. The goal is for this transparency to enhance market competition and lower health-care costs.
As a group health-plan sponsor, U-M is required to post the following health-care information monthly on a public website:
In-network provider rates for covered items and services
Out-of-network allowed amounts and billed charges for covered items and services, if 20 or more claims in the 90-day period are included in the file
Access Blue Cross Blue Shield of Michigan’s machine-readable files to download the table of contents that contains web addresses for the .Json format files with in-network negotiated rates and out-of-network allowed amounts and historical billed charges. You will need to copy the URLs in the table of contents and paste in your browser to download the machine-readable files.
The information contained in this machine-readable file may be difficult to access without certain technology.
These files may be large and require a computer that can download at least up to 1TB (terabyte) of data. Most modern hard drives store half of this amount of data. Based on your computer’s storage and hard drive, attempting to open or download large files may cause instabilities in Windows, cause performance issues resulting in downloads that could take hours, days or weeks, depending on the file size and hard-drive combination. For reference: 1TB = 243 high-definition streaming movies (average 2 hours per movie).
This mandate is a building block for future customer-facing mandates, including a Price Transparency Tool and an Advanced Explanation of Benefits.
The data in the files may not be useful for the average consumer. For example, facilities that are paid based on a percent of charge will not have a dollar amount representing the amount paid for a service.
The machine-readable files will be updated monthly to ensure accuracy of the data and reflect changes in pricing and regulatory requirements.