Please fill out the form completely:
Member Information
Name
Date of Birth (mm/dd/yyyy) Benefit Plan Number if Known
Contact Information of Person Filing Request for External Review
Check one:
Subscriber/Policy Holder
Authorized Representative
Member
If the person filing the request for external review is someone other than the member, please submit the Authorized
Representative Form with this request. On the next page, you can find further instructions under “Who may file a
request for external review?”
Name of Person Completing This Form
Address
City State ZIP
Daytime Phone Number Email
Date of service and services received for the disputed claim:
Date of Service (mm/dd/yyyy) Services Received
Health Care Provider Name
Briefly discuss why you disagree with this decision (attach additional information if available):
Signature Date (mm/dd/yyyy)
Return the completed form, your denial notice and authorized representative form
(if you have an authorized representative) to:
Mail: BCBSND
PO Box 1570
Fargo, ND 58107-1570
Fax: 701-277-2209
Be certain to keep copies of this form, your denial notice and all documents and correspondence related to this claim.
29380895 • 8-19
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Member External Review Form
Grandfathered
click to sign
signature
click to edit
Important Information About
Your Rights to External Review
What if I need help understanding a denial?
If you need help understanding this notice or our decision to deny you a service or coverage, contact
Member Services by calling the phone number on the back of your BCBSND member ID card.
What if I don’t agree with a denial?
For certain types of claims, you are entitled to request an independent, external review of our decision.
Contact Member Services by calling the number on the back of your BCBSND member ID card with any
questions regarding your right to an external review.
How do I file a request for external review?
Complete the Member External Review Form located on the BCBSND website under Members/Forms at
BCBSND.com/members/forms. Make a copy, and mail the document to Blue Cross Blue Shield of North
Dakota, PO Box 1570, Fargo, ND 58107-1570 or fax it to 701-277-2209. Once your request is received,
BCBSND will review the request for eligibility for external review.
What if my situation is urgent?
If your situation meets the definition of urgent under the law, the external review of your claim will be
conducted as expeditiously as possible. Generally, an urgent situation is one in which your health may be
in serious jeopardy, or in the opinion of your physician, you may experience pain that cannot be adequately
controlled while you wait for a decision on the external review of your claim. If you believe your situation is
urgent, you may request an expedited external review by completing the Member External Review Form
and indicating that it is urgent under the Date of Service for the disputed claim.
Who may file a request for external review?
You or someone you name to act for you (your authorized representative) may file a request for external
review. The Authorized Representative Form and instructions on how to complete it are located on the
BCBSND website under Members/Forms at BCBSND.com/members/forms.
Can I provide additional information about my claim?
Yes, once your external review is initiated, you will receive instructions on how to supply additional information.
Can I request copies of information relevant to my claim?
Yes, you may request copies (free of charge). Contact Member Services by calling the number on the back
of your BCBSND member ID card.
What happens next?
If you request an external review, an independent review organization will review our decision and provide
you with a written determination. If this organization decides to overturn our decision, we will provide
coverage or payment for your health care item or service.
4510 13
th
Avenue South, Fargo, North Dakota 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
8-19
In accordance with federal regulations, Blue Cross Blue Shield of North Dakota is required to provide you the
following disclosure:
Blue Cross Blue Shield of North Dakota complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex. Blue Cross Blue Shield of North Dakota does not exclude people or treat them differently because of
race, color, national origin, age, disability, gender identity, sexual orientation or sex.
Blue Cross Blue Shield of North Dakota:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, please call Member Services at 1-844-363-8457 (toll-free) or through the
North Dakota Relay at 1-800-366-6888 or 711.
If you believe that Blue Cross Blue Shield of North Dakota has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, gender identity, sexual orientation
or sex, you can file a grievance with:
Civil Rights Coordinator
4510 13th Ave S
Fargo, ND 58121
701-297-1638 or North Dakota Relay at 800-366-6888 or 711
701-282-1804 (fax)
CivilRightsCoordinator@bcbsnd.com (email) (Communication by unencrypted email presents a risk.)
You can file a grievance in person or by mail, fax, or email within 180 days of the date of the alleged
discrimination. Grievance forms are available at http://www.bcbsnd.com/report or by calling 1-844-363-8457.
If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
800-368-1019 or 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Español (Spanish)
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Deutsch (German)
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-844-363-8457 (TTY: 1-800-366-6888 oder 711).
中文 (Chinese)
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-844-363-8457TTY1-800-366-6888
711)。
Oroomiffa (Oromo)
XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa
1-844-363-8457 (TTY: 1-800-366-6888 ykn 711).
Tiếng Vit (Vietnamese)
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-844-363-8457 (TTY: 1-800-366-6888 hoặc 711).
Ikirundi (Bantu Kirundi)
ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu.
Woterefona 1-844-363-8457 (TTY: 1-800-366-6888 canke 711).
اﻟر (Arabic)
ﻣﻠﺣ وظ ﺔ: إذا ﻛﻧت دث اذر ا ﻠﻐ، ن دﻣﺎ ت ا ﻣ ﺳدة ا ﻠﻐو وار ك ﻟﻣن. ا ل رم
844-363-8457-1 م ھ ف ا م و ا م :
1-800-366-6888 أو 711(.
Kiswahili (Swahili)
KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo.
Piga simu 1-844-363-8457 (TTY: 1-800-366-6888 au 711).
Русский (Russian)
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-844-363-8457 (телетайп: 1-800-366-6888 или 711).
日本語
(Japanese)
注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-844-363-8457
TTY: 1-800-366-6888 または 711)まで、お電話にてご連絡ください。
नेपाल& (Nepali)
!यान %दन
होस: तपाइ/ले नेपाल2 बो4न
5छ भन तपाइ/को 9नि;त भाष सहायता सेवाह> 9नःश
4 >पमा उपलCध फोन
Hहोस
1-844-363-8457 (%ट%टवाइ: 1-800-366-6888 वा 711)
Français (French)
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-844-363-8457 (ATS : 1-800-366-6888 ou 711).
한국어 (Korean)
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하 있습니다. 1-844-363-8457
(TTY: 1-800-366-6888
또는 711)번으 전화해 주십시.
Tagalog (Tagalog Filipino)
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-844-363-8457 (TTY: 1-800-366-6888 o 711).
Norsk (Norwegian)
MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-844-363-8457
(TTY: 1-800-366-6888 eller 711).
Diné Bizaad (Navajo)
Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee ákáánída’áwo’dę
́
ę
́
’, t’áá jiik’eh, éí ná hólǫ
́
,
kojį’ hódíílnih 1-844-363-8457 (TTY: 1-800-366-6888 éí doodagó 711.)