Blue Cross Blue Shield of Michigan
Member Appeal Form
Mailing Address:
Blue Cross Blue Shield of Michigan
Blue Cross
600 E. Lafayette Blvd., M.C. CS3A
Blue Shield
Detroit, MI 48226-2998
FAX: 877-348-2210
Enrollee/Patient Information Section
Enrollee’s Name
Enrollee ID
Group Number
Patient's Name (if different from enrollee)
Relationship to Enrollee
Daytime Telephone Number
Self
Spouse
Dependent
Address
City
State
Zip Code
Claim Detail Section
Date of Service
Location of Service
Type of Service
Provider Name
To assist us in reviewing your appeal, please summarize the issue and action desired, and attach all supporting documentation.
To qualify for an appeal, we must receive your written request no more than 180 days after you receive the claim denial notice.
Your Signature:
Date:
.
If you are the person who received the services and you want someone else to speak on your behalf, please complete the Designation of Authorized
Representative for Appeal form.
If you are completing this form for someone else, please have him/her complete the Designation of Authorized Representative for Appeal form for you to
represent him or her on this appeal.
If you are a provider representing a member, you must include a completed and signed Designation of Authorized Representative for Appeal form. If you
have not been named an authorized representative and wish to file an appeal as a provider, refer to WebDENIS for the Provider Appeal form.
Administered by Blue Cross Blue Shield of Michigan, an independent licensee of the Blue Cross and Blue Shield Association
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