Making Claims

Following instructions for claims submissions reduces delays

Extended Health claims

You must submit all eligible extended health claims to the insurer by June 30 or December 31 (depending on your District’s policy) of the calendar year following the calendar year you incurred the expense.

If you terminate employment with the District or are no longer eligible for the PEBT Benefits Program. In that case you must submit all claims incurred before your termination within 90 days after you leave or after you are no longer eligible for coverage.

Electronic Claims

When submitting an electronic claim, you must:

  • complete the claim form online and submit it electronically to the Provider before the claim deadline outlined in the summary of benefits
  • keep original receipts and documentation to support the claim for 12 months from the date you submit the claim to the provider
  • if the claim is selected for review by the provider, you must submit the original receipts and supporting documentation electronically or by mail to the provider within 21 calendar days. If the provider does not receive this information within this time, your claim will be refused, and your ability to submit electronic claims will be removed.

The provider reserves the right to remove your ability to submit electronic claims if you provide false, incomplete or misleading claims information. You must submit paper claims with supporting receipts and documentation in such circumstances.

You must provide an explanation or proof to support the claim or any other information the provider considers necessary.

Payment of the claim will be directed to you unless the provider agrees to your request to assign payment directly to a third-party.

Pay Direct

If you have a pay-direct drug card, provided your pharmacy is connected to our electronic processing system, the provider will pay them directly for prescription drugs and testing supplies for diabetics covered under your plan. Simply show the pharmacist your ID card. The pharmacist will charge you only for amounts not covered by the provider. If you or the pharmacy do not have access to this system, or for other expenses, please follow the instructions in the paper claims section.

Paper Claims

Because the provider does not return receipts after the claim is processed, they suggest you keep a photocopy of the receipts you submit. The provider will send you a remittance statement for your records each time you submit a claim.

If you have duplicate coverage, please review the coordination of benefits section. You must complete two separate claim forms (one for the primary plan and one for the secondary plan). Then you submit the remittance statement from the first plan to the second plan. Because claims information regarding the other plan is not retained in our files, be sure to provide information on the second plan on both claim forms. Incomplete claims will be returned for clarification.

Certain medical expenses are covered under the provincial/territorial plans. If you submit your claim to the provider before you submit your claim to the provincial/territorial plans, the provider will deduct what the provincial/territorial plans, would normally pay from your claim. The balance of the claim is then paid according to the plan design selected by your employer.

Accumulate receipts, and when reasonable reimbursement is due, submit a claim as follows:

  • Obtain a claim form from the forms section of this website, from PBC’s website at www.pac.bluecross.ca/caresnet, or from your School District Benefits Administrator.
  • Follow the instructions on the claim form. Please include original receipts and all other requested information with your claim to avoid delay in claims payment. (Photocopies of receipts are acceptable only when accompanied by a claims payment statement from another carrier).
  • The provider must receive the original claim form and original receipts. They will not accept faxed or scanned claim forms and/or receipts.

For questions concerning your claims’ status, you can contact PBC’s Call Centre. You can also view the status of your claims by accessing your Member Profile on PBC’s site.

Out-Of-Country claims

You must complete an Emergency Out-of-Province Claim form and forward it to Pacific Blue Cross with attached itemized bills outlining the services you were charged for.

Pacific Blue Cross will coordinate your claim with the Medical Services Plan of British Columbia directly on your behalf.

Medical referral travel benefit (MRTB) claims

You must submit all eligible medical referral travel benefit (MRTB) claims to the provider within 90 days of incurring the expense.

To submit MRTB claims, please send a signed and dated letter of referral from the doctor and a completed claim form supplied by your district benefits administrator to the provider with original receipts.

For questions concerning the status of your claims, you can contact PBC’s Call Centre You can also view the status of your claims by accessing your Member Profile on PBC’s site.

Dental claims

Present your ID card to your dentist’s office. It is important to ask if your dental benefits will cover the entire cost of your treatment. To avoid any misunderstanding, it is suggested that your dentist submit an outline of the proposed services to the provider before you start treatment. This is important, especially when your dentist recommends extensive dental work. This will help you understand what portion of the dentist’s bill you must pay in the event that you wish to proceed with the treatment recommended by your dentist.

We suggest you submit claims within 90 days of the completed date of services (earlier if possible). Failure to submit a claim within the 90-day limit will not invalidate the claim if submitted as soon as reasonably possible. However, in no event will PBC pay any claim or adjustment received later than 12 months from the date the service is performed.

PBC requires a separate claim form for each member of your family who has received dental services. Be sure to include the following information on the claim form:

  • name of the dentist
  • name and birthdate of the person receiving the dental care
  • your policy and ID numbers (this information is on your ID card)
  • your home mailing address
  • whether you have coverage through another plan.

Claim information regarding the other carrier is not retained on PBC’s files. If you or your dependents are covered by two plans, your dentist must complete two separate dental claim forms (one for each plan). Incomplete claims will be returned for clarification.

Before your dentist starts treatment, please ask how billing is made. PBC may pay in either of two ways:

  • If you have paid your dentist directly, PBC will reimburse you the benefit amount when PBC receives:
    • a claim form signed by the patient that is either submitted with a receipt or is signed by the dental provider showing the services performed and the fee charged, or
    • an electronic claim showing the services performed and the fee charged. The dental provider must have the patient’s consent on file to permit the disclosure of the patient’s personal information between the dental office and PBC.
  • For pay direct claims, PBC will pay the benefit amount to the dentist directly for services provided under this benefit plan when PBC receives:
    • a claim form showing the services performed and the fee charged, signed by the patient and the dental provider or
    • an electronic claim showing the services performed and the fee charged. The dental provider must have the patient’s consent on file to disclose the patient’s personal information between the dental office and PBC.

Orthodontic Claims Procedures

Receipts:

  • Please submit original receipts, as photocopies are not accepted. Do not hold receipts until the treatment is completed.

Claiming deadlines:

  • We suggest that you submit orthodontic claims within 90 days of the date the payment was due to your orthodontist (the due date).
  • Reimbursement is made if the complete and correct claims information is received within 12 months of the due date. However, no benefit is payable for claims not received within 12 months of the due date.

Treatment plan

  • Have your orthodontist complete the “Certified Specialist in Orthodontics Standard Information Form” (the treatment plan) before treatment starts. The treatment plan must include a brief description of the treatment to be performed, a breakdown of the fees to be charged, and the estimated length of treatment.
  • If the payment schedule or treatment changes, PBC requires a revised treatment plan for review.
  • PBC will retain your treatment plan on file. If PBC does not have your treatment plan on file, they are unable to pay:
    • your initial fee/down payment
    • your monthly/quarterly fees
    • one-time appliance fees
  • Claims for consultations, exams and records (x-rays, study models, etc.) will be reimbursed without a treatment plan on file.

Monthly or quarterly fees:

  • If you pay in monthly or quarterly installments, submit receipts for the monthly or quarterly fees regularly – as treatment progresses. Claims receipts over 12 months old that PBC receives will not be reimbursed.
  • If you paid any amount to the dentist before treatment is complete, PBC will allow an initial payment amount and then prorate the balance into monthly payments to you throughout the treatment plan period.
  • As long as your coverage is effective, monthly or quarterly reimbursements will be made until the dollar maximum is reached or the treatment is complete, whichever occurs first.

For questions concerning the status of your claims, you can either contact PBC’s Call Centre directly You can also view the status of your claims by accessing your Member Profile on PBC’s site.

Coordinating extended health and dental claims with your spouse’s coverage

If duplicate coverage is allowed, PBC pays claims based on the rules of the Canadian Life and Health Insurance Association guidelines. They are:

  • The member is always the primary claimant. The spouse is always the secondary claimant.
  • Dependent children are always covered primarily by the parent with the earliest birthdate in the year (month and day).
  • In situations of separation or divorce, the following order applies:
    • the plan of the parent with custody of the child
    • the plan of the spouse of the parent with custody of the child
    • the plan of the parent not having custody of the child
    • the plan of the spouse of the parent not having custody of the child

Total reimbursement shall never exceed 100% of the eligible expenses.

Joint Early Intervention Services (JEIS)

Short term disability (weekly indemnity) claims

To apply for short-term disability benefits, please complete the Short-Term Disability Claim form which will be provided to you and the district by your Health Care Management Specialist at Desjardins Insurance. The district benefits administrator will complete the employer’s statement, and you will then complete the employee’s statement and forward it to the Provider.

Long Term Disability claims

Life or Accidental Death & Dismemberment claims

In the event of accidental injury or death, you or your beneficiary should contact the School District Benefits Administrator as soon as possible. Instructions and/or referrals will be provided to you at that time.