Additional Information Form
Additional Information requested may be submitted with the letter received or this form.
DO NOT USE THIS FORM UNLESS YOU HAVE RECEIVED A REQUEST FOR INFORMATION.
Original Claims should not be submitted with this form.
Submit only one form per patient.
***Inquiries received without the required information below may not be reviewed.***
Claim Number:
(For multiple claims provide additional claim number below)
Group Number: Prex (3 character alpha): Member Identication Number:
Patient Name: (Last, First)
Date(s) of Service: Total Billed Amount:
Provider Name: NPI:
Contact Person: Phone Number:
Additional Information requested:
REMINDERS
Mail inquiries to: Blue Cross and Blue Shield of Texas
P.O. Box 660044
Dallas, TX 75266-0044
Claim Review requests – If you did not receive a letter requesting additional information but are requesting a review of a previously adjudicated
claim, use the Claim Review Form located at bcbstx.com/provider.
Corrected Claim requests should be submitted as electronic replacement claims, or on a paper claim form along with a Corrected Claim
Review Form available on our website at bcbstx.com/provider.
To view Claim Status online utilize the Claim Research Tool (CRT) on the Availity
TM
Web Portal at availity.com.
Additional Information Form
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides
administrative services to BCBSTX. BCBSTX makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Availity. If you have any questions
about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Blue Cross
®
,
Blue Shield
®
and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
732367.0816
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