Bluecross Blueshield Of Texas Provider Appeal Request Form
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1Provider Appeal Request Form
Submission of this form constitutes agreement not to bill the patient during the dispute process.
Please complete the form below. Fields with an asterisk ( * ) are required.
Be specific when completing the “Description of Dispute” and “Expected Outcome.”
Provide additional information to support the description of the dispute.
Mail or Fax the completed form to: Blue Cross and Blue Shield of Texas
Attn: Complaint and Appeal Department
P.O. Box 27838
Albuquerque, NM 87125-7838
FAX: (855) 235-1055
Provider Name*:
National Provider Identifier (NPI) Number:
Texas Provider Identifier (TPI) Number:
Rendering Provider NPI Number:
Tax ID Number:
Street Address*:
City*:
State*:
ZIP code*:
Provider Type:
MD
Mental Health
Hospital
ASC
SNF
DME
Rehab
Home Health
Ambulance
Other (please specify):
CLAIM INFORMATION
Patient Name*:
Date of Birth:
Health Plan ID Number*:
Patient Account Number:
Original Claim ID Number:
Service “From/To” Dates* (required for claim, billing, and reimbursement of overpayment disputes):
/
Original Claim Amount Billed:
Original Claim Amount Paid:
Description of Dispute*:
Expected Outcome*:
Contact Name (please print)*:
Title:
Phone Number*:
Fax Number:
Signature:
Date:
Check here if medical records are attached.
Check here if additional information is attached.
For Health Plan Use Only
Tracking Number:
Provider ID #:
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue
Shield Association.
PWP-9000-15
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