Transcription of Claim Review Form - BCBSTX
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Claim Review Form - BCBSTX
You must check one of the following:c Additional Information requested by BCBS (example COB, Medicare EOMB)c Medical Recordsc Claim Reviewc ClaimCheck /ClaimsXtenTMPlease include detailed information as to the nature of your Review . If a corrected Claim has been attached, please specify the corrections that were Name:NPI Number:Billing Address:City:State:Zip:Email Address:Fax Number:Contact Person:Phone Number:INSTRUCTIONS FOR COMPLETING THE Claim Review FORM (Submit only one patient per form)A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association and ClaimCheck are trademarks of McKesson Information Solutions, Review Form** This form is not necessary if you
Member’s Identification Number: (Include 3 character alpha prefix) Member’s Name: (Last Name, First Name) Patient’s Name: (Last Name, First Name) Date(s) of Service and Billed Amount: DCN (Claim Number Assigned by BCBS) (Do not resubmit the claim unless there are corrections.)
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