Capital Blue Cross Provider Appeal PDF Details

This appeal document (NF-632, issued May 2008) allows members and healthcare providers to formally challenge a claim denial or denial of service from Capital BlueCross. The Capital Blue Cross provider appeal form gives members a structured path to dispute initial determinations and seek reconsideration.

To be considered, an appeal must be submitted within 180 days of the initial determination. Members send the completed paperwork by mail or fax to the Member Appeals Department, along with any supporting documentation relevant to the case.

The appeal requires detailed information about the member, the service or procedure in question, and the stated reason for the challenge. Members who want assistance can complete the built-in authorization section to appoint a Designated Appeals Representative.

Need a related insurance appeal document? You may also find these helpful: health insurance appeal request form, health plan appeal form, or the Aetna appeal form for other insurers.

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

How to Fill Out Member Appeal Form

Member Appeal Form at a glance

What it is: Member Appeal Form: to appeal a claim or denial of service in whole or in part, your request must be within 180 days of the initial determination.

Who signs: Sign on the Member Signature line and enter the Date.

A filled-in Member Appeal Form example: a member appeals a denied claim

Member Appeal Form example filled out, example: a member appeals a denied claim
Maria Sample appeals a denied claim using the Member Appeal Form. She files within 180 days of the initial determination, naming a hospital, a doctor and another provider. The picture shows page one, and none of its entries is real. Medicare Number is left blank because Maria has no Medicare coverage.

How to fill out Member Appeal Form, box by box

Member Information

Member Appeal Form example filled out, member Information

Under Member Information, enter the Member Name and the Date of Birth.

Enter the Address, City, State and ZIP Code.

Enter the Daytime Telephone and the Evening Telephone.

Enter the Identii cation Number and the Medicare Number.

Enter the Group Name and the Group Number.

Claim/Service You are Appealing

Member Appeal Form example filled out, claim/Service You are Appealing

Under Claim/Service You are Appealing, enter the Hospital, with its City, State and ZIP Code.

Enter the Doctor, with the City, State and ZIP Code.

Enter the Other Provider, with the City, State and ZIP Code.

Enter the Service/Procedure, the Date of Service, the Claim Number and the Authorization Number.

Reason for the Appeal

Member Appeal Form example filled out, reason for the Appeal

Write the Reason for the Appeal.

Your request must be within 180 days of the initial determination. Attach copies of all documentation in relation to the appeal and include any additional information which may support the appeal. This form and any accompanying documents may be mailed or faxed to the Member Appeals Department, Capital BlueCross, P.O. Box 779518, Harrisburg, PA 17177-9518, Fax: 717-541-6915.

Member Signature

Member Appeal Form example filled out, member Signature

Sign on the Member Signature line and enter the Date.

More rules for Member Appeal Form

If appointing someone to represent you during the course of the appeal, your representative must complete this portion.

The member signs on Signature of Member and enters the Date.

Under Section 2, to be completed by the Representative, the representative fills in the blank after I, to accept the above referenced appointment, and fills in what they are after I am a/an of the Member.

The representative signs on Signature of Representative and enters the Name of Representative and the Date.

Sources

[1] Member Appeal Form NF-632 (5/2008), Capital BlueCross (the Official source link on this page).

Capital Blue Cross Provider Appeal Form isn’t the one you’re looking for?

Related Documents

  • Benefeds Belated Enrollment

    "... This form is only for approval of belated Fed Vip Enrollment Change to or Cancellation of an Existing Fed vip Enrollment. If your request does not involve federal benets, please fill in your le new ..."

  • Blackfeet Enrollment

    "... black feet tribe enrollment per capita department po box 850 browning montana 59417 ph 4063383533 fax 4063385233 address change form date dear enrolled black feet tribal member it is important that you update your mailing address with the black feet enrollment per capita department on regular basis please be advised that this office needs this information by november 15 th of each year to ensure accurate delivery of your annual per capita payment remember to include your minor children on this form adults 18 years older must fill out separate form that includes their children due to our policy and procedures your signature must be notarized before we can accept this form please mail this form to the above address faxed requests can be accepted if properly notarized please print the information below name enrollment 201 first middle and last dob address city state zip spouse enrollment 201 name first middle and last dob names of minor children enrollments and or dob signature spouse notary public appeared subscribed and sworn before me onthisday of 20 office use only date received notary public for the state of id checked residing at office clerk commission expires ..."

  • Caqh Provider Application

    "... Caqh Provider Application ..."

Please rate Capital Blue Cross Provider Appeal Form

2 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .