Provider Reconsideration Form - Blue Cross Blue Shield Of South Carolina

Download a blank fillable Provider Reconsideration Form - Blue Cross Blue Shield Of South Carolina 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 Provider Reconsideration Form - Blue Cross Blue Shield Of South Carolina 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.

Provider Reconsideration Form

To request a claim review, please complete this form for BlueCross BlueShield of South Carolina and BlueChoice

HealthPlan of South Carolina members. Use this form as the cover transmittal sheet for all supporting documentation.

Submission of this form without supporting documentation will not be considered. Complete or check each section, as

appropriate.

*This form is not for use to appeal an adverse benefit determination on behalf of a member. Member appeal rights must be

exercised according to the member’s specific plan requirements.

Provider Information

Provider’s Name:

NPI or Tax ID:

___________________________________________________

__________________________________

Phone Number:

Ext:

Fax Number:

_____________________________________

_________

_____________________________________

Contact Person:

Email:

_____________________________________________

___________________________________________________

Authorized Signature:

Date:____________________________

_________________________________________________________

Patient Information

Patient’s Name: ____________________________________________ Member Id: ________________________________

Claim Number: ______________________________

Date of Service: __________________________

(Do not attach claim)

Please fax or mail to (select only one):

 BlueChoice HealthPlan

Fax: 800-610-5685

Mail: P.O. Box 6170, Columbia, SC 29260

 BlueEssentials

and

Fax: 800-610-5685

Mail: P.O. Box 6170, Columbia, SC 29260

Blue Option

 State Health Plan

Fax: 803-264-4204

Mail: AX-B10, P.O. Box 100605, Columbia, SC 29260

 Federal Employee Program

Fax: 803-264-8104

Mail: AX-B05, P.O. Box 600601, Columbia, SC 29260

 Group & Individual

Fax: 803-264-4172

Mail: AX-F25, I-20 at Alpine Road, Columbia, SC 29219

 Preferred Blue

and BlueCard

Fax: 803-264-4172

Mail: AX-620, I-20 at Alpine Road, Columbia, SC 29219

Reconsideration

Brief Description of Request/Desired Action You Want us to Take as Result of This Claim Review:

____________________________________________________________________________________________________

___________________________________________________________________________________________________

Description of Documentation Included (required):_______________________________________________________

___________________________________________________________________________________________________

Note: This form is intended for use by physicians and other health care professionals in South Carolina. If you are located outside South Carolina and have

claims questions, reviews or appeals, please direct them to your local Blue Plan.

Rev. 03/16/16 (SG)