Healthy Blue is the trade name of Community Care Health Plan of Louisiana, Inc., an
independent licensee of the Blue Cross and Blue Shield Association.
MF-BLA-0006-16
Request for Continuation of Benefits Form
Thank you for choosing Healthy Blue as your health care plan. You have asked for an
appeal. If you are getting approved Healthy Blue services now, you can ask to keep
getting these services during your appeal review. This is called continuation of benefits.
It is for approved Healthy Blue services you are getting now, including:
Inpatient stays
Outpatient services
We will pay for continuation of health care services you get during the appeal and state
fair hearing review if the decision is in your favor. If the decision is made in favor of
Healthy Blue, you must pay for any and all charges during this time.
We must get your request for a continuation of benefits within 10 days from the date of
the attached letter. Your first request may be verbal. But you must also ask in writing. If
you want to keep getting benefits during the appeal, please fill out and sign this form.
Member Name:
Parent’s or Guardian’s Name (if service is for a child):
Healthy Blue ID #:
Reference #:
Name of doctor who wants to give or who gave you the service:
Type of service you want to continue getting:
Sign and send this form to:
Central Appeals Processing
Healthy Blue
P.O. Box 62429
Virginia Beach, VA 23466-2429
Fax: 1-888-873-7308
By signing this form, you know that if your services continue and the services were not
medically necessary or right, you must pay for these services.
Signature: Date:
Member, Parent, Legal Guardian or Approved Representative*
*An approved representative must be named by the member, parent or legal guardian.
The provider may act on behalf of the member with the member’s and/or responsible
party’s written consent. An approved representative cannot make health care decisions
that involve the financial duty of the member, parent or legal guardian unless it is put in
writing.
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