Blue Cross Blue Shield Of Michigan - Member Appeal Form

Download a blank fillable Blue Cross Blue Shield Of Michigan - Member Appeal Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Blue Cross Blue Shield Of Michigan - Member Appeal Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

                             
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
SEP 16 Page 1 of 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go