Capital Blue Cross Provider Appeal Form PDF Details

Capital Blue Cross provides their customers with a Provider Appeal Form to submit if they are not satisfied with the service they received from a healthcare provider. The form can be used to ask for a refund, discontinue service, or file a complaint. Instructions and a checklist are included to help ensure that the appeal is complete and accurate. Filing an appeal can be an effective way to get the help and resolution you need. If you have had a negative experience with a healthcare provider, the Capital Blue Cross Provider Appeal Form can be used to resolve the situation. The form includes instructions and a checklist to make sure that your appeal is complete and accurate.

These are some details about capital blue cross provider appeal form. Our suggestion is that you read this material before you decide to start working with the form.

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

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:

 

 

 

 

 

 

 

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