An expedited pre-service clinical appeal may be requested if the member, an authorized representative or the physician feels
that non-approval of the requested service may seriously jeopardize the member’s health. An appeal also may be submitted if,
in the opinion of the practitioner with knowledge of the member’s medical condition, non-approval would subject the member
to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request.
The medical service or treatment should meet the following criteria:
• Satisfy the above description as urgent in nature
• Has not yet taken place or is ongoing
• Determined by Blue Cross and Blue Shield of Illinois
(BCBSIL) to be medically unnecessary, experimental,
investigational or medically unproven
• Not covered for clinical reasons or not in benet
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 03376.1119
Instructions
Once it has been determined that the BCBSIL criteria for submitting an expedited clinical pre-service appeal have
been met, please proceed as follows:
1. Fill out the form below, using the tab key to advance from eld to eld
2. Print out your completed form and use it as your cover sheet
3. Include medical records, oce notes and any other necessary documentation to support your request
4. Fax your request form and supporting documentation to BCBSIL at 918-551-2011, Attention: Appeals Department
Expedited Pre-service Clinical
Appeal Request Form
Today’s Date: _____________________________
Patient Information
Patient First Name:______________________________________Patient Last Name:_________________________________________________
Patient’s Date of Birth:_______________________________________________________________________________________________________
Member First Name:____________________________________Member Last Name: _______________________________________________
Member ID Number (include 3-character prex):_________________________________________Group Number:_______________________
Case Information
CPT/HCPCS Code:____________________________________________________________________________________________________________
Place of Service (Facility Name):_______________________________________________________________________________________________
Case Number (if applicable):___________________________________________________________________________________________________
Procedure(s) Non-allowed: __________________________________________________________________________________________________
Physician/Facility/Provider Information
Physician Name (Attending Provider Full Name):________________________________________________________________________________
NPI: _________________________________________________________________________________________________________________________
Phone Number:_______________________________________________Fax Number: _________________________________________________
Facility or Provider/Group Name: ___________________________________________________________________________________________
Appellant Information
Name of Individual Submitting Appeal: ______________________________________________________________________________________
Phone Number:___________________________________________Fax Number:______________________________________________________
