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Get TX BCBS Physician/Professional Provider & Facility Ancillary Request for Claim Appeal/Reconsideration Review Form 2008-2024

S submitted. Please attach supporting documentation to facilitate your review, for example the operative report, or medical records, etc. This form must be placed on top of the correspondence you are submitting. Please check one of the boxes below: Refund Dispute Corrected Claim Attached Appeal Other Response to Medical Records Request Voluntary Submission of Medical Records Reason for Review Please include detailed information as to the nature of your claim appeal/reconsideration review. If a.

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