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May have in relation to this appeal and include any additional information which may support your appeal. This form and any accompanying documents may be mailed or faxed to: Premera Blue Cross Member Appeals Department PO Box 91102 Seattle, WA 98111-9202 Fax: 425-918-5592 Member Information Member Name: Date of Birth: Identification Number: Group/Policy Number: Address: City: State: ZIP: Home Phone#: Cell Phone#: Email Address: Claim/Service You are Appealing Have services already be.

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To request a health plan appeal you can: Fill out a Health Plan Appeal Request Form. Mail or fax it to us using the address or fax number listed at the top of the form. Call the BCBSTX Customer Advocate Department toll-free at 1-888-657-6061 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., Central Time.

Fax general appeals to 425-918-5592.

If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, gender identity, or sexual orientation, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals, PO Box 91102, Seattle, WA 98111, ...

Level 2 Appeal: Disagreement with the determination of the first level of appeal. Second-level appeals must be submitted in writing. Must be received within 30 calendar days from the participant's receipt of the Level 1 Appeal notification.

When you're looking up a claim using member information, make sure you click on the provider name to get details like the claim receipt date, pended reasons, and claim payment codes. We process most of our claims within 30 days and we pay claims every Saturday and on the last day of the month.

Timely Claims Submission Ideally, we'd like you to submit claims within 60 calendar days of the covered services, but no later than 365 calendar days. For most plans, we'll deny claims received more than 12 months after the date of service with no member responsibility.

Submit corrected claims within 30 working days of receiving a request for missing or additional information. If you have questions about a specific claim, contact Blue Shield of California Provider Services.

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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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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
Premera Com Appeal Forms
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