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Form X16156r05 - Provider Claim Adjustment/status Check/appeal Form - Blue Cross Blue Shield Of Minnesota And Blue Plus

PROVIDER CLAIM ADJUSTMENT / STATUS CHECK / APPEAL FORM

Blue Cross Blue Shield of Minnesota and Blue Plus

One form per request or appeal.

Indicate the number of related requests/appeals being submitted for the same member. Specify ____ of ____ (e.g., 1 of 5).

Today’s Date: _______________________

Contact Person:________________________________________

Phone _____________________

Fax ______________________

BCBSMN Tax ID or Provider ID:_______________________ NPI: __________________

Provider Name: _____________________________Provider Return Address:

_____________________________________________

BCBSMN Member ID#:

Patient Name:

Claim #:

□

Patient Account:

Blue Card

Service Date(s) in question:

Plan Code __________

Group #:

Charge for service in question:

A claim adjustment request is based upon a correction and/or new

Claim Adjustment Request/Status Check

information for a previously processed claim. Adjustment requests are not

appeals. We can not adjust claims to deviate from contract

benefits.

For Status Check: Please check Provider Web Self Service or call Provider Services. Please wait 30 days from the date you submitted

the claim before checking on the status.

Enter the remark code

COMMENTS: ______________________________________________________________________________________________

_______________________________________________________________________________________________

Other Carrier Paid (include EOB – Explanation of Benefits)

Medicare (include EOMB)

No-Fault auto insurance

Workers’ Compensation

_____________________________________________________

An appeal is a request for reconsideration of a previously processed

Appeal

(Attach supporting documentation – Please refer to the

service (denial, payment reduction, coverage termination, etc.)

Provider Policy and Procedure Manual for instructions)

Enter remark code

______________________________________________________________________________________

COMMENTS:

________________________________________________________________________________________________

Website:

click on ‘For Health Care Providers’ for the Provider Policy & Procedure Manual,

Forms: Other

Mail to: Blue Cross Blue Shield of Minnesota

FAX to: 651-662-2745

Attn: {Please indicate} Appeals or Claim Adjustments

PO Box 64560

St Paul, MN 55164-0560

Form X16156R05 (01/09)

Form X16156r05 - Provider Claim Adjustment/status Check/appeal Form - Blue Cross Blue Shield Of Minnesota And Blue Plus

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