Fillable Appeal Form Instructions (Blue Cross Blue Shield of North Dakota)

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Appeal Form Instructions (Blue Cross Blue Shield of North Dakota)

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Page 1 of 3
29378957 • 2-19
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
NOTE: The appeal form must be completed in its entirety. An incomplete form will be denied as an
invalid appeal request.
Member Instructions
1. Complete Sections A and D of this form
2. Include or attach any additional information you think will help a favorable decision to be made on
your adverse determination.
If you need assistance completing this form, please call the number on the back of your member
ID card.
3. Return completed forms by:
• Fax: (701) 277-2209
• Mail: Blue Cross Blue Shield of North Dakota
PO Box 1570
Fargo, ND 58107-1570
Authorized Representative Instructions
1. Complete Sections A, B, and D of this form
2. Include or attach any additional information you think will help a favorable decision to be made on
your adverse determination.
If you need assistance completing this form, please call the number on the back of the policy holder’s
ID card.
3. Return completed forms by:
• Fax: (701) 277-2209
• Mail: Blue Cross Blue Shield of North Dakota
PO Box 1570
Fargo, ND 58107-1570
Provider Instructions
1. Complete Sections A, C, and D of this form
2. Include or attach any additional information you think will help a favorable decision to be made on
your adverse determination. Requests submitted without documentation will be denied as an invalid
appeal. Please note, the appeal form should not be used to submit a claim correction or as a venue
for submitting medical records or EOBs.
If you need assistance completing this form, please call Provider Services at 1-800-368-2312.
3. Return completed forms by:
• Fax: (701) 277-2209
• Mail: Blue Cross Blue Shield of North Dakota
PO Box 1570
Fargo, ND 58107-1570
Appeal Form Instructions
Page 2 of 3
29378957 • 2-19
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Section A: Member Information
Last Name First Name MI
Member ID Number Date of Birth
Phone Claim or Reference Number (if applicable)
Provider Name Date of Service Total Charge Amount
Section B: Authorized Representative Information
Last Name First Name MI
Relationship to Member
If you are not currently an Authorized Representative, you will need to complete an
Authorization to Disclose Health Information (ADHI) form along with this form.
Download the ADHI form here
Phone Number Address
City State ZIP
Section C: Provider Information
Last Name First Name MI NPI No.
Check One:
Provider on behalf of self
Provider on behalf of member
If you are submitting this request on behalf of the member, please complete the Authorization to
Release Information (ARI) form along with this form.
Download the ARI form here
Phone Number Fax Number Address
City State ZIP
Appeal Form
Page 3 of 3
29378957 • 2-19
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Section D: Appeal Information
Explain what you are disagreeing with and why you are requesting review of the plan’s
benefit determination. Include or attach any additional information that would help us
make a favorable decision.
Appeal Form
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Appeal Form Instructions (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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