Fillable Fee Schedule Request Form printable pdf download

Fee Schedule Request Form –

Blue Choice PPO

The fee schedule—Schedule of Maximum Allowances (SMA)—is a key component of your contractual relationship with Blue Cross and Blue Shield of Illinois (BCBSIL). The fee schedule is a

listing of accepted charges or established allowances for specified procedure codes. The fee schedule allowances are reviewed and updated periodically. It is important to be aware of specific

procedure code changes and allowance updates. These allowances do not guarantee payment for all services submitted.

All fields indicated below are required.

Fax your completed, signed form to BCBSIL at 618-997-9480 to obtain the CPT code fee schedule for the Blue Choice PPO network.

You will receive an email from BCBSIL with the requested information. As a result, you will be required to adjust your email settings to allow email from .

You should receive the information in your regular email or spam folder within one week. Please make sure you indicate the appropriate recipient email address below.

Fee Schedule (select one): c Area A

c Area B

I am requesting:

If you are unsure of your area, leave blank and a Customer Advocate will complete on your behalf.

Provider Name

Attention:

Billing NPI Number:

City:

State:

Zip:

County:

Address:

Telephone Number:

Fax Number:

Email Address:

Date:

NDC reimbursement resources are available to BCBSIL contracted providers who have registered for our Blue Access for Providers

secure site. To log in or register for Blue Access for

Providers, look for the National Drug Codes (NDCs) Billing Resources box on our Provider Home page at

For non-Illinois providers, please contact your local plan unless you are a DME, Specialty Pharmacy or Laboratory Provider.

C O N F I DE N TI A L I T Y A GR EE M E NT

This Confidentiality Agreement (“Agreement”) is entered between Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”) and ____________________.

WHEREAS, HCSC and ________________ are in the process of good faith negotiations toward the end of ______________’s agreeing to <<continue

to>>

participate in

the HCSC <<Blue Choice PPO>>network; and

WHEREAS, _________________________ has requested the opportunity to review HCSC’s <<Blue Choice

PPO>>

Schedule of Maximum Allowances in order to assist

in its final determination as whether __________________________ will agree to <<continue

to>>

participate in the HCSC <<Blue Choice

PPO>>

network; and

WHEREAS, HCSC has advised __________________ of the highly confidential and proprietary nature of HCSC’s <<Blue Choice

PPO>>

Schedule of Maximum Allowances but is

agreeable to disclosing the <<Blue Choice

PPO>>

Schedule of Maximum Allowances subject to the terms and conditions hereinafter set forth;

NOW THEREFORE, the parties hereto agree as follows:

1. HCSC shall disclose to ________________________, upon submission of their National Provider Identifier (NPI) number, a copy of the <<Blue Choice

PPO>>

Schedule of

Maximum Allowances (the “Schedule”) or those parts thereof as pertinent to ___________________________’s areas of practice.

2. ________________ agrees and acknowledges that the Schedule is highly confidential and proprietary information of HCSC. ________________ agrees that such

information shall be disclosed only to those individuals at _____________ responsible for the final decision as to whether or not to participate, or continue to participate as the case

may be, in the HCSC <<Blue Choice

PPO>>

network.

3. ________________ agrees that it will not give, disclose, sell, or transfer to others, or cause or permit to be given, disclosed, sold, or transferred to others the Schedule, or any

part thereof, or use or permit to be used such information for other than the purposes herein above described.

4. ________________ agrees that no copies of the Schedule or any part thereof will be made or disclosed other than for the purposes discussed herein without the express prior

written authorization of HCSC.

5. This Confidentiality Agreement shall be binding and the obligations arising under the Confidentiality Agreement will continue in the event that ________________

decides not to <<continue

to>>

participate in HCSC’s <<Blue Choice

PPO>>

Network, the Schedule of Maximum Allowances and all copies thereof shall be destroyed at such time.

HEALTH CARE SERVICE CORPORATION, a Mutual Legal Reserve Company (“HCSC”)

______________________________________________

Name of Provider

NPI Number: _______________________________________

By:____________________________________________

Title:___________________________________________

Authorized Representative:________________________________