Form 352192.1015 "Expedited Pre-service Clinical Appeal Form - Bluecross Blueshield of Montana" - Montana

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Download Form 352192.1015 "Expedited Pre-service Clinical Appeal Form - Bluecross Blueshield of Montana" - Montana

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Expedited Pre-service
Clinical Appeal Request Form
An expedited pre-service clinical appeal may be requested if the member, an authorized representative or the physician feels that non-approval
of the requested service may seriously jeopardize the member’s health. An appeal also may be submitted if, in the opinion of the practitioner with
knowledge of the member’s medical condition, non-approval would subject the member to severe pain that cannot be adequately managed without
the care or treatment that is the subject of the request.
The medical service or treatment should meet the following criteria:
Determined by BCBSMT to be medically unnecessary, experimental,
Satisfy the above description as urgent in nature
investigational or medically unproven
Has not yet taken place or is ongoing
Not covered for clinical reasons or not in benefit
Instructions
Once it has been determined that the Blue Cross and Blue Shield of Montana (BCBSMT) criteria for submitting an expedited clinical
pre-service appeal have been met, please proceed as follows:
1. Fill out the form below, using the tab key to advance from field to field
2. Print out your completed form and use it as your cover sheet
3. Include medical records, office notes and any other necessary documentation to support your request
4. Fax your request form and supporting documentation to BCBSMT at 866-589-8256, Attention: Appeals Department
_____________________________
Today’s Date:
Patient Information
_________________________________
__________________________________
Patient First Name:
Patient Last Name:
____________________________________________________________________________
Patient’s Date of Birth:
______________________________
___________________________________
Member First Name:
Member Last Name:
_______________________________
_____________________
Member ID Number
Group Number:_
(include 3-character alpha prefix):
Case Information
_______________________________________________________________________________
CPT/HCPCS Code:
________________________________________________________________________
Place of Service
:
(Facility Name)
__________________________________________________________________________
Case Number
:
(if applicable)
__________________________________________________________________________
Procedure(s) Non-allowed:
Physician/Facility/Provider Information
________________________________________________________________
Physician Name
:
(Attending Provider Full Name)
______________________________________________________________________________________
NPI:
__________________________________
______________________________________
Phone Number:
Fax Number:
_____________________________________________________________________
Facility or Provider/Group Name:
Appellant Information
___________________________________________________________________
Name of Individual Submitting Appeal:
__________________________________
_______________________________________
Phone Number:
Fax Number:
You may also submit an expedited pre-service clinical appeal request by calling BCBSMT. Call BCBSMT at 800-447-7828 or 855-258-8471 with details
regarding your expedited pre-service clinical appeal request.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
352192.1015
Expedited Pre-service
Clinical Appeal Request Form
An expedited pre-service clinical appeal may be requested if the member, an authorized representative or the physician feels that non-approval
of the requested service may seriously jeopardize the member’s health. An appeal also may be submitted if, in the opinion of the practitioner with
knowledge of the member’s medical condition, non-approval would subject the member to severe pain that cannot be adequately managed without
the care or treatment that is the subject of the request.
The medical service or treatment should meet the following criteria:
Determined by BCBSMT to be medically unnecessary, experimental,
Satisfy the above description as urgent in nature
investigational or medically unproven
Has not yet taken place or is ongoing
Not covered for clinical reasons or not in benefit
Instructions
Once it has been determined that the Blue Cross and Blue Shield of Montana (BCBSMT) criteria for submitting an expedited clinical
pre-service appeal have been met, please proceed as follows:
1. Fill out the form below, using the tab key to advance from field to field
2. Print out your completed form and use it as your cover sheet
3. Include medical records, office notes and any other necessary documentation to support your request
4. Fax your request form and supporting documentation to BCBSMT at 866-589-8256, Attention: Appeals Department
_____________________________
Today’s Date:
Patient Information
_________________________________
__________________________________
Patient First Name:
Patient Last Name:
____________________________________________________________________________
Patient’s Date of Birth:
______________________________
___________________________________
Member First Name:
Member Last Name:
_______________________________
_____________________
Member ID Number
Group Number:_
(include 3-character alpha prefix):
Case Information
_______________________________________________________________________________
CPT/HCPCS Code:
________________________________________________________________________
Place of Service
:
(Facility Name)
__________________________________________________________________________
Case Number
:
(if applicable)
__________________________________________________________________________
Procedure(s) Non-allowed:
Physician/Facility/Provider Information
________________________________________________________________
Physician Name
:
(Attending Provider Full Name)
______________________________________________________________________________________
NPI:
__________________________________
______________________________________
Phone Number:
Fax Number:
_____________________________________________________________________
Facility or Provider/Group Name:
Appellant Information
___________________________________________________________________
Name of Individual Submitting Appeal:
__________________________________
_______________________________________
Phone Number:
Fax Number:
You may also submit an expedited pre-service clinical appeal request by calling BCBSMT. Call BCBSMT at 800-447-7828 or 855-258-8471 with details
regarding your expedited pre-service clinical appeal request.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
352192.1015