Fillable Member Appeal Form Instructions to help you complete

Fill Online, Printable, Fillable, Blank Member Appeal Form Instructions to help you complete Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Member Appeal Form Instructions to help you complete

On average this form takes 5 minutes to complete

The Member Appeal Form Instructions to help you complete form is 3 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 19 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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: 919-765-4409
Fax (State Health Plan PPO): 919-765-2322
Member Rights and Appeals
Blue Cross and Blue Shield of North Carolina
P
.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
1 of 3
Member Appeal Form
Member Information
Today’s Date ID Number Date of Birth
First Name Last Name Primary Phone Number
Street Address Alternate Phone Number
City, State, ZIP
Patient Information (If same as above, leave blank)
First Name Last Name Date of Birth
Service/Claim Information
Claim Number(s) Reference/Authorization Number(s) (if applicable)
Provider Name Date(s) of Service(s)
2 of 3
Fax:
919-765-4409
Fax (S
tate Health Plan PPO): 919-765-2322
M
ember Rights and Appeals
Blue Cross and Blue Shield of North Carolina
P.O. Box 30055
Durham, NC 27702-3055
In accordance with Blue Cross and Blue Shield of North Carolina (Blue Cross NC) policies
, all information contained herein or
attached is subject to review by any Blue Cross NC staff member as is appropriate.
This form is for ling a Level 1 or Level 2 member appeal.
NOT to be used for Federal Employee Program (FEP).
In order to start this process, this form must be completed in its entirety, signed, dated and submitted for review within 180 days of
notification of the date 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. Please attach copies of all
documentation you may have in relation to this appeal and include any additional information that may support your appeal. This
form and information may be submitted via fax or mail to:
Reason for Appeal (If additional space is needed, attach additional detail as necessary)
Print First and Last Name Signature
BLUE CROSS
®
, BLUE SHIELD
®
, and the Cross and Shield symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent
Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association. U36019a, 7/20.
3 of 3
Member Appeal Form
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Member Appeal Form Instructions to help you complete

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 April 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document