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On is required for preauthorization consideration. For formulary information and to download additional forms, please visit www.bcbsil.com Today s Date: PATIENT INFORMATION Patient Name (First): Last: M: DOB (mm/dd/yyyy): Patient Address: City, State, Zip Patient Telephone: INSURANCE INFORMATION BCBS ID Number: Group Number: PHYSICIAN/CLINIC INFORMATION Prescriber Name: Physician NPI#: Specialty: Clinic Name: Clinic Address: City, State, Zip: Contact Name: Phone #: Secure Fax.

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Claims may be submitted one-at-a-time by entering information directly into an online claim form on the vendor portal; or batch claims may be submitted via your Practice Management System (check with your software vendor to ensure compatibility).

Any claim that can be submitted on paper can be submitted electronically. If you need more information on how to submit claims electronically call (312) 653-7954 or log on to .bcbsil.com.

Submit the medical records that you can through the Availity Portal. For any additional medical records, use the Send Attachment option in the Attachments application in Availity.

Contact Us Contact Name/DescriptionURL/Email/Phone/FaxBehavioral Health Unit1-800-851-7498 FEP: 1-800-779-4602 Fax: 877-361-7656 BCBSIL BH Unit PO Box 660240 Dallas, TX 75266-0240BlueCard® Hotline Call for out-of-state member eligibility and benefits1-800-676-BLUE (2583)11 more rows

How to access and use Availity Attachments Log in to Availity. Select Claims & Payments from the navigation menu. Select Attachments — New. Within the tool, select Send Attachment then Predetermination Attachment. Download, complete and save the Predetermination Request Form. Complete the required data elements.

1-877-860-2837 (TTY/TDD: 711) The call is free. A live agent can be reached from 8 a.m. to 5 p.m. Central Time, Monday through Friday. Self-service or a voicemail can be used 24/7, including weekends and holidays.

BCBSIL only accepts medical records through the Availity Portal in response to requests for additional medical record documentation used for quality and risk adjustment purposes. Administrator Instructions: Select Availity Enrollment Center > Medical Attachments Setup, then enter required data.

Blue Cross and Blue Shield of Illinois (BCBSIL) is a customer-owned health insurance company serving Illinois residents. The company offers individuals and families healthcare and prescription drug coverage through its Blue Choice Preferred PPO, Blue Precision HMO, and BlueCare Direct HMO plans.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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
DMCA Policy
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:
1-877-389-0141
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