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Provider Refund Form - BCBSIL

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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association submit refunds to:Blue Cross and Blue Shield of Illinois Refund and Box 94075, Palatine, IL 60094-4075Provider Refund FormProvider Information:Name:Address:Contact Name:Phone Number:NPI Number: Refund Information:1Group # From PCSMember From PCSADM DateClaim/DCN #Patient s NameProvider Patient #Letter Reference # Refund Amount:Reason/RemarksSignatureDateCheck NumberCheck Date2Group # From PCSMember From PCSADM DateClaim/DCN #Patient s NameProvider Patient #Letter Reference # Refund Amount:Reason/Remarks3Group # From PCSMember From PCSADM DateClaim/DCN #Patient s NameProvider Patient #Letter Reference # Refund Amount:Reason/Remarks4Group # From PCSMember From PCSADM DateClaim/DCN #Patient s NameProvider Patient #Letter Reference # Refund Amount:R

provider cancelled charge for any reason; or claim incorrectly paid per contract. “Duplicate Payment” A duplicate payment has been received from BlueCross for one instance of service (e.g. same group and member number). “Not our Patient” …

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