Welcome to the Claims Submission Page
- Electronic Claims Payor ID 56215
- Securely upload a Claim Document Securely upload a claim document
- Fax (336) 499-4006
- Mailing Address
PO Box 571137
Winston Salem, NC 27157-1137
Member Claim Form
- Member Claim Information for Out-of-Network Providers
- Out of Network Provider requirements:
- Provider must be fully licensed
- Your plan must have Out of Network Benefits
- Complete page one and either attach super bill from provider or ask the provider to fill out page two.
- Payments can either be sent directly to member or to provider depending on providers preference. Leave box 13 blank to receive payment.
- Call CBHA claims department at 1-800-475-7900 Monday-Friday from 8:30-5:00 pm for assistance in filling out form.