Capital Blue Cross Provider Appeal Form PDF Details

When it comes to ensuring that healthcare needs are met within the context of insurance policies and agreements, the Capital Blue Cross Provider Appeal Form serves as a critical tool for both members and healthcare providers in addressing disputes related to claims or denials of service. This form is officially titled NF-632 (5/2008) and is designed to facilitate the appeal process by allowing members to formally challenge an initial determination made by Capital BlueCross. For an appeal to be considered, it must be filed within 180 days of the initial determination, necessitating the submission of the appeal form alongside any pertinent documentation that may support the member's case. The submission details are clearly outlined, offering options to mail or fax the completed form and accompanying evidence to the Member Appeals Department. Furthermore, the form requires detailed information about the member, the service or procedure in question, and the reason for the appeal. Additionally, should members choose to appoint a representative to manage and advocate for their appeal, a section dedicated to authorizing a Designated Appeals Representative is included. This provision emphasizes the importance of member representation in the appeals process, allowing for more specialized or personal support when navigating the nuances of healthcare disputes. By encompassing these elements, the Capital Blue Cross Provider Appeal Form plays an indispensable role in advocating for members' healthcare rights and ensuring they have the means to seek redress for decisions affecting their access to necessary medical services.

QuestionAnswer
Form NameCapital Blue Cross Provider Appeal Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namescapital blue cross provider dispute form, capital bcbs appealk, provider capital blue cross appeals form, capital blue cross appeal

Form Preview Example

NF-632 (5/2008)

Member Appeal Form

To appeal a claim or denial of service in whole or in part your request must be iled within 180 days of the initial determination. Please attach copies of all documentation you may have in relation to this appeal and include any additional information which may support your appeal. This form and any accompanying documents may be mailed or faxed as follows to:

Member Appeals Department

Capital BlueCross

P.O. Box 779518

Harrisburg, PA 17177-9518

Fax: 717-541-6915

Member Information

Member Name:

 

 

Date of Birth:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

City:

State:

 

ZIP Code:

 

 

 

 

Daytime Telephone:

Evening Telephone:

 

 

 

 

 

 

Identiication Number:

Medicare Number:

 

 

 

 

 

 

Group Name:

Group Number:

 

 

 

 

 

 

 

Claim/Service You are Appealing

Hospital:

City:

State:

ZIP Code:

 

 

 

Doctor:

 

 

 

 

 

City:

State:

ZIP Code:

 

 

 

Other Provider:

 

 

 

 

 

City:

State:

ZIP Code:

 

 

 

Service/Procedure

Date of Service:

Claim Number:

Authorization Number:

 

 

 

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

Reason for the Appeal

Member Signature:

Date:

If appointing someone to ile the appeal on your behalf and to represent you during the course of the appeal, your representative must complete this portion:

Authorization of Designated Appeals Representative

Subscriber:

Todays Date:

Subscriber ID Number:

Group Number:

Section I—Authorization of Designated Appeals Representative

To be completed by the Member:

I authorizeto act as my representative in connection with my complaint, grievance, or appeal with Capital BlueCross, or Keystone Health Plan® Central. I authorize this individual to make any request; to present or elicit evidence; to obtain information; and to receive any notice in connection with my complaint, grievance, or appeal. I understand that personal health information related to my claim may be disclosed to my representative in the course of the complaint, grievance, or appeal.

I agree that the representative will act on my behalf regarding my complaint, grievance, or appeal. I understand that:

1.I will not be able to ile my own complaint, grievance, or appeal concerning these same services, nor will any other representative I appoint, unless this consent is rescinded in writing.

2.I have a right to rescind this consent at any time. My legal representative also has the right to rescind this consent at any time.

I have read this consent or have had it read to me and it has been explained to my satisfaction. I understand this information, and grant my consent for my representative to ile a complaint, grievance, and appeal on my behalf.

Member Name:

 

 

Date of Birth:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

City:

State:

 

ZIP Code:

 

 

 

 

Daytime Telephone:

Evening Telephone:

 

 

 

 

 

 

Signature of Member:

 

 

Date:

 

 

 

 

 

Section 2—Acceptance of Authorization

To be completed by the Representative:

I,

 

 

hereby accept the above referenced

 

 

appointment. I am a/an

 

 

of the Member and will

(STATUS OR RELATIONSHIP TO THE PARTY, E.G. RELATIVE, ATTORNEY, FRIEND) advocate on their behalf in regards to the complaint, grievance, or appeal.

Signature of Representative:

Name of Representative:

 

 

Date:

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

City:

State:

 

ZIP Code:

 

 

 

 

Daytime Telephone:

Evening Telephone:

 

 

 

 

 

 

 

How to Edit Capital Blue Cross Provider Appeal Form Online for Free

There's nothing complicated about filling in the capital blue cross appeals department after you open our PDF editor. By following these simple steps, you will get the ready file in the minimum time period possible.

Step 1: Choose the button "Get Form Here".

Step 2: At the moment, you can start modifying your capital blue cross appeals department. The multifunctional toolbar is available to you - insert, delete, adjust, highlight, and undertake other sorts of commands with the text in the file.

Fill out the capital blue cross appeals department PDF by entering the data meant for each individual part.

provider capital blue cross appeals form spaces to fill in

Remember to fill up the City, Other Provider, City, ServiceProcedure Date of Service, State, State, ZIP Code, ZIP Code, Claim Number, Authorization Number, and Health care benefit programs space with the necessary information.

part 2 to filling out provider capital blue cross appeals form

You can be requested for certain significant data if you need to fill up the Reason for the Appeal area.

provider capital blue cross appeals form Reason for the Appeal fields to fill out

The field Member Signature, Date, If appointing someone to i le the, Authorization of Designated, Subscriber, Subscriber ID Number, Todays Date, Group Number, Section IAuthorization of, and to act as my representative in should be where you add all sides' rights and responsibilities.

provider capital blue cross appeals form Member Signature, Date, If appointing someone to i le the, Authorization of Designated, Subscriber, Subscriber ID Number, Todays Date, Group Number, Section IAuthorization of, and to act as my representative in blanks to complete

Review the sections Member Name, Address, City, Date of Birth, State, ZIP Code, Daytime Telephone, Evening Telephone, Signature of Member, Date, Section Acceptance of, hereby accept the above referenced, appointment I am aan, STATUS OR RELATIONSHIP TO THE, and of the Member and will and then fill them out.

provider capital blue cross appeals form Member Name, Address, City, Date of Birth, State, ZIP Code, Daytime Telephone, Evening Telephone, Signature of Member, Date, Section Acceptance of, hereby accept the above referenced, appointment I am aan, STATUS OR RELATIONSHIP TO THE, and of the Member and will blanks to insert

Step 3: Click the button "Done". Your PDF form may be exported. You may download it to your device or send it by email.

Step 4: It's possible to make duplicates of the form tostay clear of any kind of future problems. Don't get worried, we cannot publish or track your information.

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