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  • Florida Blue External Reviews Form

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Peals Department within four (4) months after receipt of your final adverse benefit determination regarding coverage of a health care service or treatment. Applicant Name: COVERED PERSON/PATIENT INFORMATION Covered Person Name: Patient Name: Address: Covered Person Phone #: Home ( ) Work #: ( ) INSURANCE INFORMATION Insurer/Administrator/HMO Name: Contract Number: Telephone #: ( ) Insurer/Administrator/HMO Mailing Address: PO Box 44197, Jacksonville, FL 32231-4197 EMPLOYER INFORMATION E.

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You can ask us to reconsider by filing a grievance with us. You can look in your “Evidence of Coverage” for information about how to file a grievance, contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) or click here for more information.

You can also request a copy by: Emailing 1095Breprint@floridablue.com. Sending your request in writing to Customer Service at 4800 Deerwood Campus Parkway, Jacksonville, FL 32246. Calling us at 800-352-2583.

Contact us by email at rpmchartprocurement@floridablue.com, by fax at 904-301-1557 or toll free call at 1-855-622- 2735. Be sure to include your name, contact information and provider group.

You must file your claim within one year from the date of service. You can submit your claim any time during the year. Use a separate claim form for each family member and each physician or supplier. All sections of the form must be filled out completely or your claim may be returned to you.

About Florida Blue Florida Blue is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. For more information, visit .FloridaBlue.com.

NOTE: Fax Expedited Review Requests to 1-904-565-6637 to ensure immediate receipt.

To complete this request, your treating health care provider must fill out the attached form stating that a delay would seriously jeopardize the life or health of the patient or would jeopardize the patient's ability to regain maximum function.

Visit .Availity.com; 2. Select My Payer Portals; and 3. Select the Florida Blue PASSPORT link • In PASSPORT, select the green Electronic Appeal tile to start the process. The electronic appeal process is currently not available for the Federal Employee Program (FEP) or BlueCard claims.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232