Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
PROVIDER INFORMATION
PROVIDER NAME NATIONAL PROVIDER IDENTIFIER (NPI)
STREET ADDRESS
CITY STATE ZIP
CONTACT PERSON FOR DISPUTE FOLLOW UP PHONE
MEMBER INFORMATION (A separate form must be completed for each member)
MEMBER NAME
DATE OF BIRTH MEMBER ID
AUTHORIZATION NUMBER SERVICE FROM TO
DATE
REASON FOR DISPUTE (A detailed explanation must be provided)
INCORRECT CRITERIA/MEDICAL POLICY UTILIZED
GOOD CAUSE FOR FAILURE TO OBTAIN AUTHORIZATION (PLEASE SPECIFY)
INCORRECT INFORMATION PROVIDED BY MCO
MEMBER ELIGIBILITY CONCERN
OTHER (PLEASE SPECIFY)
TO SUBMIT BY MAIL
Blue Cross Community Health Plan
Provider Authorization Disputes
PO Box 660906
Dallas, TX 75266
TO SUBMIT BY FAX 312-653-9443
Important reminders: Attach additional supporting information for your dispute. If clinical information
is not submitted with the dispute form, your request will not be accepted. The processing time for
provider service dispute resolution requests is 30 calendar days from receipt of the request.
Provider Service Authorization Dispute Resolution Request
This form should be used to dispute a service authorization denial or a reduction, suspension, or termination of a
previously authorized service. This form is NOT to be used for claim/billing issues or disputes.
For claim/billing issues or disputes, please use the following link:
https://www.bcbsil.com/pdf/network/medicaid_claims_inquiry_dispute_request_form.pdf*
*Please note: Timely ling for a service authorization disputes is 60 days from the date of the disputed denial or claim notication.
237879.0221
