BlueCross BlueShield of Illinois Medicare Advantage Claim Review Form
This form is used for the review of previously adjudicated claims for BlueCross BlueShield of Illinois Medicare Advantage. Ensure not to attach original claims to this form, and submit only one form per patient. Required information must be filled out for review.
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How do I fill this out?
To fill out this form, provide the required patient and claim information accurately. Attach any necessary supporting documentation. Detailed instructions are provided below.
How to fill out the BlueCross BlueShield of Illinois Medicare Advantage Claim Review Form?
1
Fill in the claim number.
2
Provide the group number and prefix.
3
Enter the member identification number and patient name.
4
Add date(s) of service, total billed amount, and provider name.
5
Attach supporting documentation if necessary and mail the form.
Who needs the BlueCross BlueShield of Illinois Medicare Advantage Claim Review Form?
1
Healthcare providers reviewing previously adjudicated claims.
2
Patients who need to dispute or review claims on their behalf.
3
Billing departments handling Medicare Advantage claims.
4
Care coordinators assisting patients with medical claims.
5
Insurance agents managing clients' claims.
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What are the instructions for submitting this form?
To submit this form, ensure all required fields are accurately filled and supporting documentation is attached if necessary. Mail the completed form to BlueCross BlueShield of Illinois, P.O. Box 4555, Scranton, PA 18505. Double-check for completion to avoid processing delays. Direct any queries to the contact person mentioned in the form.
What are the important dates for this form in 2024 and 2025?
Ensure to submit your review requests promptly to avoid delays. Deadlines for 2024 and 2025 are not specified.
What is the purpose of this form?
The purpose of this form is to provide a standardized method for requesting claim reviews for BlueCross BlueShield of Illinois Medicare Advantage. It ensures that all necessary information is collected to process the review efficiently. By using this form, healthcare providers and patients can streamline the claims review process.
Tell me about this form and its components and fields line-by-line.
- 1. Claim Number: The unique identification number for the claim.
- 2. Group Number: The number identifying the group plan.
- 3. Prefix (3 Character Alpha): The three-character alphabetic prefix associated with the member's plan.
- 4. Member Identification Number: The unique ID number of the member.
- 5. Patient Name: Full name of the patient.
- 6. Date(s) of Service: The dates on which services were provided.
- 7. Total Billed Amount: The total amount billed for the services.
- 8. Provider Name: The name of the healthcare provider.
- 9. NPI: National Provider Identifier.
- 10. Contact Person: Name of the person to contact regarding the claim.
- 11. Phone Number: Contact phone number.
- 12. Detailed Information: Any additional information pertinent to the review request.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or denial of your claim review request.
- Missed Deadlines: Your review request may not be considered if submitted past the deadline.
- Incomplete Information: Lack of required information may prevent your claim from being reviewed.
- Denied Claims: Failure to submit could lead to a denial of the claim review.
How do I know when to use this form?
- 1. Review Disputes: When you disagree with a claim decision and seek reevaluation.
- 2. Update Claim Details: To provide additional information or corrections to a claim.
- 3. Claim Denial Appeals: Request a formal review of denied claims.
Frequently Asked Questions
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Yes, you can share the filled-out form via email or generate a shareable link from PrintFriendly.
What type of information do I need to provide on this form?
You need to provide patient information, claim details, service dates, billed amounts, and provider information.
Is it possible to attach supporting documentation?
Yes, attach any necessary supporting documentation to your form before mailing it.
Can I save my progress while editing the form?
Yes, you can save your progress in the PrintFriendly editor and continue editing later.
Is there a limit to how many forms can be submitted?
Submit one form per patient to ensure proper review.
Will PrintFriendly keep a copy of my edits?
You can download and keep the edited PDF; PrintFriendly does not store your edits.
How do I obtain a claim number?
Refer to your original claim documents or contact your provider for the claim number.
Where do I send the completed form?
Mail the completed form to Blue Cross and Blue Shield of Illinois, P.O. Box 4555, Scranton, PA 18505.
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