A provider may request an independent external review only after exhausting BCBSND’s provider appeal process. Pursuant to
North Dakota state law, the non-prevailing party is responsible for payment of the $750 review fee after the nal determination
has been made.
Return this form, your denial notice and the authorized representative form (if you have an authorized representative) by:
PO Box 1570
Fargo, ND 58107-1570
Fax: 701-277-2209
Member Information
Provider Name
NPI Specialty
Patient First Name Patient Last Name Date of Birth (MM/DD/YYYY)
Member ID Date of Service Diagnosis
Procedure Claim Number
Summary of Appeal Description
Completed by Phone Number Date (MM/DD/YYYY)
Signature Date (MM/DD/YYYY)
Be certain to keep copies of this form, your denial notice and all documents and correspondence related to this claim.
Provider Independent External
Review Request
29379409 • 1-20
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
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