Fillable Bcbsaz Corrected Claim Form printable pdf download

Bcbsaz Corrected Claim Form

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BCBSAZ Corrected Claim Form

If you are not able to submit your corrected claim electronically, this form must be completed and included

with your request, along with a copy of the original claim. Requests sent without a completed form will be

returned.

1. Provide the following information:

Today’s Date

Member Name

Provider Name

Member ID

Provider NPI/TIN

BCBSAZ Claim #

Provider Fax #

Patient ID #

Provider Phone #

Group # (CHS only)

2. Identify the information being changed and briefly explain why it is necessary:

3. Attach a copy of the original claim, showing the correction.

Note: Do not send medical records.

4. Submit this form (along with a copy of the original claim) by fax to:

BlueCard (out-of-state Blue plan) Corrected Claims

602-864-3116

Corporate Health Services (CHS) Corrected Claims

602-864-2249

Federal Employee Program (FEP) Corrected Claims

602-864-4670 or 602-864-2031

Note: ID number begins with “R” followed by 8 numeric characters.

All other BCBSAZ Corrected Claims

602-864-3116

Or mail this form (along with a copy of the original claim) to:

BCBSAZ

P.O. Box 13466

Phoenix, AZ 85002

Thank you!

Rev 06/01/16

Bcbsaz Corrected Claim Form

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