Member Appeal Form
Timeframe to request an appeal: This form must be completed and received at Blue Cross and Blue Shield of North
Carolina (Blue Cross NC) within 180 days of the date on the notice of the adverse benefit determination. Please note, for
members who are part of an ERISA employer group plan, deadlines have been extended by federal law during the
COVID-19 national emergency.
How to complete this form: Please complete as much of the form as you can.
• Member Information: This information may be found on your Blue Cross NC ID card.
• Patient Information: Provide information for the person the request is for. If same as member information, leave blank.
• Service/Claim Information: Tell us about the service, claim and/or item for which you are appealing. This information may be
found on correspondence from Blue Cross NC.
• Reason for Appeal: Tell us why you are requesting an appeal. Use additional paper if necessary.
• Print First and Last Name: Print the name of person listed in the Patient Information section if 18 and older. If under age 18,
print the name of the parent/guardian.
• Signature: Signature of person listed in the Patient Information section if 18 and older. If under age 18 the signature of
parent/guardian is required.
How to submit this form: Enter your information directly, then print your completed form. Or, print a blank form to ll in by hand.
Mail or fax the completed form together with any supporting documents to:
Fax (State Health Plan PPO): 919-765-2322
Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
.O. Box 30055
Durham, NC 27702-3055
Choose an authorized representative: You have the right to choose an authorized representative to help you with your appeal.
To appoint an authorized representative, complete the Member Appeal Representation Authorization Form.
What happens next: We’ll send you a letter letting you know that we received your appeal request. We’ll review your appeal,
including all supporting documentation provided.
Questions: Please contact Customer Service at the number on the back of your Blue Cross NC member ID card.
Instructions to help you complete the Member Appeal Form
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