Provider Appeals and Medical Review Forms

In order to better assist you with medical necessity and billing disputes, we have posted our Provider Appeals Process. Before submitting an appeal, please review the Provider Appeals Process to determine the level of appeal you need to file.

Medical Review Requests

After reviewing the appeals process, you may submit a written appeal for a medical review using our Medical Review Request form. This form ensures the medical information you fax or mail gets to the right area at BlueCross. Please include this form with any medical records you submit to us. You can fax or mail the form, but faxing it will help expedite the process.

You need to complete the entire form, but there are several important items to note:

Patient Information: Be sure to check the type of plan. This ensures the request will route the records to one of five areas: State Health Plan, Federal Employee Program (FEP), Group & Individual, Preferred Blue® or another BlueCross BlueShield plan.

Reason for Review/Appeal Request: You must include a reason for the request, supportive medical documentation and a legible remittance copy. Please check the applicable documentation types indicating you have attached this information. Please do not attach the claim.

Faxes: Be sure use the form as the fax cover page for any documentation you send in. Using the form as a cover sheet will help make sure your records go to the right department.

Mailing Addresses: If you choose to mail the form and documentation, be sure to use the complete address as listed on the form to expedite processing.