Medicare Advantage (Medical) claim form
Coverage decisions are decisions we make about whether a service is covered by the plan and the amount, if any, we are required to pay for the service. Coverage decisions are also call organization determinations. If you are not satisfied with the outcome of a coverage decision, you can appeal the decision by requesting a plan reconsideration. Learn more about coverage decisions and reconsiderations, and filing grievances. Call a customer service representative to get an aggregate number of grievances and appeals filed with BlueCross Secure.
To request a coverage decision or reconsideration:
Call 1-855-204-2744 (TTY 711)
Fax your request to 1-803-264-9581
Email your request to firstname.lastname@example.org
Download a reconsideration request form
You can name another person to act as your “representative” and ask for a coverage decision or reconsideration on your behalf, such as a friend, relative, doctor or other prescriber. To have a representative act on your behalf, both you and the representative must sign the Appointment of Representative Form.