Blue Cross Claim Review Form - Original claims should not be attached to a review form. Below are reminders for how to correctly use the claim review form. Blue cross and blue shield of texas (bcbstx) has revised our claim review form. Web this form is only to be used for a review of a previously adjudicated claim. Web submit an appeal, send us a completed request for claim review form. See the corrected claim form or the additional information form. Do not use this form to submit a corrected claim or to respond to an additional information request from blue cross and blue shield of illinois. Each claim review form must include the bcbsil claim number (the document control number, or dcn), along with the key data elements specified on the forms. Bcbstx will complete the first claim review within 45 days following the receipt of your request for a first claim review. When to use the claim review form:
Web submit an appeal, send us a completed request for claim review form. You can submit up to two appeals for the same denied service within one year of the date the claim was denied. This form is available on the provider website under education and reference/forms. When to use the claim review form: This is due within one year of the date the claim was denied. See the corrected claim form or the additional information form. Below are reminders for how to correctly use the claim review form. Web this form is only to be used for a review of a previously adjudicated claim. Bcbstx will complete the first claim review within 45 days following the receipt of your request for a first claim review. Do not use this form to submit a corrected claim or to respond to an additional information request from blue cross and blue shield of illinois. Each claim review form must include the bcbsil claim number (the document control number, or dcn), along with the key data elements specified on the forms. Where to mail your completed documents. Original claims should not be attached to a review form. There are two (2) levels of claim reviews available to you. Blue cross and blue shield of texas (bcbstx) has revised our claim review form. Claim review requests must be submitted in writing on the claim review form. Web for providers who need to submit claim review requests via paper, one of the specific claim review forms listed below must be utilized.