BlueCard Claims Appeal Form - Horizon Blue Cross Blue ...€¦ · BlueCard Claims Appeal Form...
Transcript of BlueCard Claims Appeal Form - Horizon Blue Cross Blue ...€¦ · BlueCard Claims Appeal Form...
BlueCard Claims Appeal Form
Submit to: BlueCard Claim AppealsHorizon Blue Cross Blue Shield of NJP.O. Box 1301Neptune, NJ 07754-1301
Office/Facility Name: ___________________________________________________________________________________________
Office/Facility Address: _________________________________ City: ______________________ State: _______ ZIP: ___________
Business Office Representative: __________________________________________________________________________________
Telephone Number: _______ – _______ – _____________ Date of Request: _____ / _____ / ________MM DD YYYY
Subscriber’s Name: ________________________________________________ ______________________ ___________Last First MI
Patient’s Name: ___________________________________________________ ______________________ ___________Last First MI
Patient’s Date of Birth: _____ / _____ / ________ Patient’s Account Number: ____________________________________________MM DD YYYY
First Date of Service: _____ / _____ / ________ Last Date of Service: _____ / _____ / ________MM DD YYYY MM DD YYYY
Details of Request:
Please submit all applicable documents to support the appeal:• The relevant CMS 1500(s) or UB04(s)• The relevant Explanation(s) of Benefits or Remittance Advice• Information previously requested that you have not yet submitted, if available• Pertinent correspondence related to this matter• A description of pertinent communications on this matter that was not in writing• Relevant sections of the National Correct Coding Initiative (CCI) or other coding support you relied upon IF the appeal concerns
the disposition of billing codes• Other documents you may believe support your position in this appeal including Medical Records/Notes
*** If you are submitting this appeal on behalf of the member please include the appropriate authorization form***
Signature: ________________________________________________________ Date: _____ / _____ / ________MM DD YYYY
5373 (W0312) An Independent Licensee of the Blue Cross and Blue Shield Association.
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