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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.

Sorry for the inconvenience

To verifty your ADHI status for this matter, call 800‑368‑2312 or for Medicaid Expansion, call 833‑777‑5779.

BCBSND cannot process this appeal without a completed Authorized Representative or Authorization to Release Information form.

  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.

  Information you will need

  Member information including member ID number

  Claim Number

  Claim charge amount

  Any information you think will help overturn the original decision such as physician's notes, operative reports, X-rays, lab results.

  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.

  Information you will need

  Member information including member ID number

  Claim Number

  Claim charge amount

  Any information you think will help overturn the original decision such as physician's notes, operative reports, X-rays, lab results.