Additional Information Form
Additional Information requested may be submitted with the letter received or this form.
DO NOT USE THIS FORM UNLESS YOU HAVE RECEIVED A REQUEST FOR INFORMATION.
Original Claims should not be submitted with this form.
Submit only one form per patient.
***Inquiries received without the required information below may not be reviewed.***
Claim Number:
(For multiple claims provide 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:
Additional Information requested:
REMINDERS
• Mail inquiries to: Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, IL 60680-4112
• Claim Review requests: If you did not receive a letter requesting additional information but are requesting a review of a
previously adjudicated claim, use the Claim Review Form located at bcbsil.com/provider.
• 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 bcbsil.com/provider.
To view Claim Status online utilize the Claim Status Tool on the Availity
®
Provider Portal at availity.com.
242500.0321
Additional Information Form
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides
administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any
questions about the products or services provided by such vendors, you should contact the vendor(s) directly.
Blue Cross and Blue Shield of Illinois, 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.
