Form D12518 - Bcbs Provider Certification Form For Expedited Appeal printable pdf download

Provider Certification Form

for Expedited Appeal

Is the appeal for a service that the patient has already received?

Yes

If “Yes,” the patient must pursue the standard appeals process and cannot use the expedited appeals process.

If “No,” continue with this form.

Provider Information

Treating Physician/Provider ________________________________________________________________________________

Phone # ____________________________________________ Fax # ____________________________________________

Address ______________________________________________________________________________________________

City _______________________________________________________ State _________ Zip Code ____________________

Patient Information

Member Name _________________________________________ Member ID # ____________________________________

Phone # ____________________________________________ Fax # ____________________________________________

Address ______________________________________________________________________________________________

City _______________________________________________________ State _________ Zip Code ____________________

What service denial is the patient appealing? __________________________________________________________

____________________________________________________________________________________________________

Explain why you believe the patient needs the requested service and why the time for the standard appeal process will harm

the patient. __________________________________________________________________________________

____________________________________________________________________________________________________

Fax this form with any supporting documentation and medical records to

BCBSAZ at (602) 544-5601

I certify, as the patient’s treating provider, that delaying the patient’s requested service for the time periods applicable to the standard appeal process is

likely to seriously jeopardize the patient’s life, health or ability to regain maximum function, cause a significant negative change in their medical condition,

or subject the patient to severe pain that cannot be adequately managed without the requested service.

Provider’s Signature

___________________________________________________________________ Date _____________

If you have questions about the appeals process or need help to prepare your Appeal, you may call BCBSAZ at (602) 864-4400

or (800) 232-2345.

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