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Web provider dispute resolution request note: Fields with an asterisk ( * ) are required. Web this form is for all providers requesting information about claims status or disputing a claim with blue cross and blue shield of illinois (bcbsil) and serving members in the state of illinois. Fields with an asterisk (*) are required.
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Provide additional information to support the description of the dispute and/or appeal. Blue shield dispute resolution office attention: Submitting a dispute on a member’s behalf. This form must be included with your request to ensure that it is routed to the appropriate area of the company, thus avoiding delays in our review process.
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Disputes submitted on a member's behalf will be treated as a member grievance and handled within the member grievance process. Submission of this form constitutes agreement not to bill the patient during the dispute resolution process. Web blue cross blue shield of texas is committed to giving health care providers with the support and assistance they need. Do not include a copy of a claim that was.