Get Request For Review Form - Blue Cross Blue Shield Of Georgia 2020-2025

Filling out the Request For Review Form for Blue Cross Blue Shield Of Georgia online is a straightforward process. This guide will walk you through each section of the form, ensuring that you provide all necessary information accurately and completely.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to begin the process of acquiring the form and open it for editing.
2. Enter the current date in the designated field to indicate when the form is being submitted.
3. Provide your name in the 'Submitted By' field.
4. Fill in the 'Member Name' section with the name of the member associated with the claim.
5. Input the 'Member ID' associated with the specific member.
6. Enter the 'Provider Name' who is requesting the review.
7. Fill in the 'Tax ID' for the provider.
8. Indicate the 'Specialty' of the provider involved.
9. Provide the 'Hospital Name' if applicable.
10. Enter the 'Hospital Tax ID' in the respective field.
11. Document the 'Date of Service' that the request pertains to.
12. Describe the 'Procedure' related to this request.
13. Select one checkbox under the 'Type of Review' section that accurately describes the nature of your request. Options include inquiry, internal appeal, reimbursement, medical necessity, UCR fee allowance/claims edit, experimental/investigational, timeliness of filing, level of care, pre-auth not on file, length of stay, other, complexity of care, or post-service review.
14. In the 'Type and Reason for Request' section, provide a detailed description of the request, including any extenuating circumstances that may apply.
15. Indicate where to mail the response by filling out the address fields provided.
16. If applicable, send the form via fax to 1-877-868-7950.
17. Review and ensure all fields are accurately filled before proceeding to save your changes, download, print, or share the form as needed.

Complete your Request For Review Form online today for efficient processing.