You need to complete the entire form, but there are several important items to note:

Patient Information: Be sure to check the type of plan. This ensures the request will route the records to one of five areas: State Health Plan, Federal Employee Program (FEP), Group & Individual, Preferred Blue or another BlueCross BlueShield plan.

Reason for Review/Appeal Request: You must include a reason for the request, supportive medical documentation and a legible remittance copy. Please check the applicable documentation types indicating you have attached this information. Please do not attach the claim.

Faxes: Be sure use the form as the fax cover page for any documentation you send in.

Mailing Addresses: If you choose to mail the form and documentation, be sure to use the complete address as listed on the form to expedite processing.

Use the form as a cover sheet. This will help make sure your records go to the right department.

Download the Medical Review Request form.