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Get TX BCBS Claim Review Form 2015-2024

Er s Name: (Last Name, First Name) Patient s Name: (Last Name, First Name) Date(s) of Service and Billed Amount: DCN (Claim Number Assigned by BCBS) (Do not resubmit the claim unless there are corrections.) This form must be placed on top of the correspondence you are submitting. Do not attach claim forms unless it is a corrected claim from the original claim listed above. Please include supporting documentation to facilitate your review. TYPE OF REVIEW You must check one of the.

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