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Details on being a Medicaid Expansion provider
The appeal form should not be used to submit a claim correction or as a venue for submitting medical records or EOBs.
Appeals must be submitted within 180 days of adverse action for commercial business and 60 days of adverse action for Medicaid Expansion.
Based on your response, this appeal cannot be submitted through this form. Please contact our Provider Services team for further assistance.
Do you have an Authorization to Release Information (ARI) form completed for this member? *
Max size for upload is 10MB. Acceptable file formats include: .pdf and image files.
Sorry for the inconvenience
Legally, BCBSND cannot process this appeal without a completed Authorization to Release Information (ARI) form.
Please complete the ARI form and return to submit your provider appeal.
Ok, we can help
To verify your ARI status for this member, call 800-368-2312.
This form is for submitting an Appeal for one member only.The member information entered below must correspond to all appeal information listed later in the form.If you are appealing for multiple members, please submit a separate form for each member.
*Required Fields
Enter the information for the rendering of billing provider associated with the Appeal.
Enter the contact information for the individual completing this appeal form. This person may receive follow-up correspondence or status updates related to the appeal form.
Enter the claim or reference number(s) you are appealing.You may include up to 8 per submission, as long as they are all for the same member.This information will be used to review your request and issue a response.
Your appeal will be reviewed within 72 hours.
Print this page for your records before submitting the appeal.
Please wait while your form is being submitted