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BCBSND to join Cambia as newest affiliated single-state Blue plan. Read More ›
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If you would like us to reconsider a previous decision about your benefits, this form will set into motion a review of the data. Please complete this form thoroughly so we can help you with a resolution.
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BCBSND cannot process this appeal without a completed Authorized Representative or Authorization to Release Information form.
Please complete the appropriate form and return to submit the appeal.
To verifty your ADHI status for this matter, call 800‑368‑2312 or for Medicaid Expansion, call 833‑777‑5779.
Information you will need
Member information including member ID number
Reference number from the determination letter you received
Any information you think will help overturn the original decision such as physician's notes, operative reports, X-rays, lab results.
Claim Number
Claim charge amount
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For a complete review and resolution, please include the provider's information below.
Max size for upload is 10MB. Acceptable file formats include: .pdf and image files.
Your appeal will be reviewed within 72 hours.
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