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
SECTION 1: MEMBER AND PROVIDER DATA (TO BE FILLED OUT BY PROVIDER)
MEMBER ID # PROVIDER ID (TIN OR NPI)
MEMBER NAME PROVIDER NAME
MEMBER DATE OF BIRTH (DOB) PROVIDER CONTACT
DME HCPC CODE(S) PROVIDER EMAIL
ADDITIONAL COMMENTS
SECTION 2: BENEFIT LIMIT VERIFICATION (TO BE FILLED OUT BY BCBSIL)
DME HCPC CODE(S) ALLOWABLE DAY SPAN
DATE SERVICE RENDERED ALLOWABLE UNITS
REMAINING ALLOWABLE UNITS UNITS USED
ADDITIONAL COMMENTS
CONFIDENTIALITY NOTICE: This communication, including any attachments, contains condential information that
may be privileged. The information is intended only for the use of individual(s) or entity to which it is addressed. If you
are not the intended recipient, any disclosure, distribution or the taking back of any action in reliance upon this
communication is prohibited and unlawful. If you received this communication in error, please notify the sender
immediately via email address listed above and destroy the original documents.
Durable Medical Equipment (DME)
Benet Limit Verication Request Form
Use this form to verify benet limit availability for Durable Medical Equipment (DME) services for members enrolled in
the Blue Cross Community Health Plans
SM
(BCCHP
SM
) or Blue Cross Community MMAI (Medicare-Medicaid Plan)
SM
plans.
Return this completed form to: BCCHP_Benet_Limit_Verication@bcbsil.com
Providers should complete section 1 of this form. BCBSIL will complete section 2.
You will receive the requested benet limit verication information within two business days.
242174.0321
