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 BCBSIL.
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 Illinois
P.O. Box 805107
Chicago, IL 60680-4112
• Additional Information requests: If you received an Additional Information request letter from BCBSIL, 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 bcbsil.com/provider. Examples of additional information include, but are not limited to:
Medical Records, Operative Reports, Coordination of Benets, Medicare Explanation of benets, etc.
• Claim Review 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 submit Claim Review requests online utilize the Claim Inquiry Resolution tool, accessible through Electronic
Refund Management (ERM) on the Availity
®
Provider Portal at availity.com.
242502.0321
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.
