Corrected Claim Form
This form is only to be used to make corrections to a previously adjudicated claim when you are unable to submit the corrections electronically.
Do not use this form to respond to an Additional Information request from BCBSTX.
Submit only one form per patient.
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Corrected Paper Claim Form Attached
***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:
Indicate the corrections requested.
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 letter 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.
• Claim Review requests – If you did not receive a request for additional information but are requesting a review of a previously adjudicated
claim please use the Claim Review Form located at bcbstx.com/provider.
To view Claim Status online, utilize the Claim Research Tool 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.
732369.0816
