Get the free Provider Inquiry/Appeal Form

This document outlines the changes to the adjustment policy regarding modifiers -24, -25, and -59 and provides a form for providers to submit inquiries or appeals to Blue Cross and Blue Shield of

How to fill out provider inquiryappeal form

How to fill out Provider Inquiry/Appeal Form

1. Obtain the Provider Inquiry/Appeal Form from the applicable website or office.
2. Fill in the provider's name, contact information, and identification number at the top of the form.
3. Clearly state the reason for the inquiry or appeal in the designated section.
4. Include relevant dates, case numbers, and any supporting documentation as attachments.
5. Review the completed form for accuracy and completeness.
6. Sign and date the form before submission.
7. Submit the form according to the instructions provided, either by mail, fax, or electronically.

Who needs Provider Inquiry/Appeal Form?

1. Healthcare providers who need clarification on claims, billing issues, or want to dispute a decision made by an insurance company.
2. Providers seeking to appeal a denial of services or coverage for a patient.
3. Administrative staff responsible for managing claims and billing processes for healthcare facilities.

For pdfFiller’s FAQs

What is Provider Inquiry/Appeal Form?

The Provider Inquiry/Appeal Form is a document used by healthcare providers to inquire about claims or to appeal decisions made regarding payments, services, or eligibility.

Who is required to file Provider Inquiry/Appeal Form?

Healthcare providers who wish to challenge a claim denial or seek clarification on a claim status are required to file the Provider Inquiry/Appeal Form.

How to fill out Provider Inquiry/Appeal Form?

To fill out the Provider Inquiry/Appeal Form, providers should accurately complete all required fields, including patient information, claim details, the reason for inquiry or appeal, and contact information.

What is the purpose of Provider Inquiry/Appeal Form?

The purpose of the Provider Inquiry/Appeal Form is to formally request a review of claims that have been denied or require further clarification, ensuring that providers can effectively communicate issues regarding reimbursements.

What information must be reported on Provider Inquiry/Appeal Form?

The information that must be reported includes the provider's details, patient information, claim numbers, dates of service, denial codes, and a detailed explanation of the reason for the inquiry or appeal.