Claim Review Form
This form is only to be used for review of a previously adjudicated claim. Original Claims should not be attached to a review form.
Do not use this form to submit a Corrected Claim or to respond to an Additional Information request from BCBSTX.
Submit only one form per patient.
***Inquiries received without the required information below may not be reviewed.***
Claim Number:
(For multiple claims provide the additional claim number below)
Group Number: Prex (3 character alpha): Member Identication Number:
Patient Name: (Last, First)
Date(s) of Service: Total Billed Amount:
Provider Name: NPI:
Contact Person: Phone Number:
Provide detailed information about your review request, including additional claim numbers, if applicable. Attach supporting documentation, if necessary.
REMINDERS
• Mail inquiries to: Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044
• Additional Information requests – If you received an Additional Information request from BCBSTX, follow the instructions provided and use
that letter as the cover sheet. If you do not have the cover sheet please use the Additional Information Form located at bcbstx.com/provider.
Examples of additional information include, but aren’t limited to: Medical Records, Operative Reports, Coordination of Benets, Medicare
Explanation of Benets, etc.
• Corrected Claim requests should be submitted as electronic replacement claims, or on a paper claim form along with a Corrected Claim
Review Form available on our website at bcbstx.com/provider.
To submit Claim Review requests online utilize the Claim Inquiry Resolution tool, accessible through Electronic Refund
Management (ERM) on the Availity
TM
Web Portal at availity.com.
Additional Information Form
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides
administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions
about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross
®
,
Blue Shield
®
and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
732368.0816
