Clinical Editing Appeal Form
For BCN HMO
(commercial), BCN Advantage
Blue Cross PPO (commercial) and Blue Cross Medicare Plus Blue
2. Check the box to indicate the appropriate line of business and refer to the associated information:
• The date the appeal is postmarked or faxed must be within 180 days of the date on the original remittance advice with the original clinical
editing denial on it. Appeals dated after the 180 days will be denied.
• * Indicates REQUIRED fields. Additional information will facilitate processing of the appeal, but if any required information is missing, the
appeal will be returned as incomplete. Please TYPE the information within the defined fields.
3. Individual provider name: 4. *Individual provider NPI:
5. *Member name:
6. *Member contract number: 7. Suffix:
8. *Date of service: 9. *Claim number (ONLY ONE claim per form):
10a. *1st (or only) procedure code being appealed: 10b. *Explanation (EX) code:
11a. 2nd procedure code being appealed (as applicable): 11b. Explanation (EX) code:
12a. 3rd procedure code being appealed (as applicable): 12b. Explanation (EX) code:
13. *Appeal submitted by: 14. *Phone #: ( )
15. *Address to send the response to:
16. Reason/rationale for appeal: (Either document this here or indicate in a letter included with this submission.)
17. Please provide supporting documentation, including, for example:
• Chart or office notes, when the code being appealed refers to an office visit or a service provided in the office
• Operative notes or surgery reports, when the procedure code being appealed refers to a surgery
• X-ray reports, when an X-ray is being appealed
• Lab or pathology reports, when a laboratory or pathology service is being appealed
• Other clinical documentation related to the procedure being appealed
Submit this completed form along with other documentation in one of the following ways:
BY MAIL (all lines of business) BY FAX IMPORTANT: Fax only one appeal at a time.
Clinical Editing Appeals
Mail Code G820
Blue Care Network
611 Cascade West Parkway, SE
Grand Rapids, MI 49546-2143
BCN HMO /
(Call Provider Inquiry
Medicare Plus Blue
Blue Cross PPO
(professional providers) or
BCN HMO (commercial) / BCN Advantage
Use this form only when appealing a clinical editing
denial decision for one of the BCN EOP codes.
Click here re. accessing the BCN codes list.
Blue Cross PPO (commercial)
Use this form only when appealing a clinical
editing denial decision for PPO EOP codes.
here re. accessing the PPO codes list.
Use this form only when appealing
a clinical editing denial decision for
EOP codes 852 and 870.