Provider Request for Appeal on Behalf of a Medicaid Member
For timely processing of your request, please attach the following information:
1. Copy of the Explanation of Benefits (EOB)/Remittance Advice and/or denial letter
2. Any additional information to support your request (i.e., medical records, etc.)
Mail completed form and any applicable documents to:
Blue Cross Community Centennial
SM
(Medicaid) Appeals Department, P.O. Box 27838, Albuquerque
NM 87125-7838 Or fax to: 888-240-3004; Attention: Appeals Coordinator
Note: Member or patient must sign at the bottom of this form designating assignment of
representation.
Please complete:
Patient Name: ________________________________________________________________
Current Address:______________________________________________________________
Phone Number: ______________________________________________________________
Date(s) of Service: ____________________________________________________________
BCBSNM Identification Number: Group Number: _________________
Provider(s) Name(s): __________________________________________________________
Provider NPI Number(s):__________________________________________________________
Provider’s reasons for this request (attach additional pages if necessary):
The following documents to support this request are enclosed:
Signature of Requestor: _____________________________ Date of Request: _______________
I (the parent/guardian or patient) authorize ___________________________________ (the provider)
to represent me in the appeal process regarding the above services
Member/Patient Signature: ___________________________________ Date: _______________
Note: If patient is under the age of 18, the signature of the parent/guardian is required.
01/10/19
Such services are funded in part with the State of New Mexico.
Blue Cross and Blue Shield of New Mexico, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association
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