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The document is a change request form for BlueCross BlueShield of Tennessee, allowing employees to add or change dependents, medical and dental coverage, life beneficiaries, and personal information. It includes sections for selecting the type of change, providing current employee details, dependent information, life insurance options, and waiving coverage. The form emphasizes confidentiality and requires signatures for acknowledgment.

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What is the fax number for BCBS of LA prior authorization?

Blue Cross and Blue Shield of Louisiana, an independent licensee of the Blue Cross and Blue Shield Association, offers Blue Advantage (PPO). The purpose of this form is to request a prior authorization for outpatient services and Part B drugs. Please fax this completed form to 1-877-528-5816, Attn. Medical Management.

What is the fax number for Bcbsil prior authorization?

Fax each completed Predetermination Request Form to 800-852-1360. If unable to fax, you may mail your request to BCBSIL, PO BOX 805107, Chicago, IL, 60680-3625.

What is the fax number for prior authorization BCBS Tennessee?

Musculoskeletal prior authorization is required for spinal surgery, joint surgery (hip, knee and shoulder) and pain management. You can request prior authorization at Availity.com or by fax at 1-866-747-0587.

What is the fax number for BCBS Tennessee authorization?

High Tech Imaging This includes: CT, CTA, MRI, MRA, MRS, Nuclear Cardiac, PET and CPT. You can verify benefits and request prior authorization at Availity.com or by phone at 1-888-693-32111-888-693-3211 or by fax at 1-888-693-3210.

What is the fax number for BCBS SC prior authorization?

Methods for Requesting Prior Authorization If you do not have an account, request one here. Fax: 813-751-3760 Submit the Preauthorization Request Form along with supporting documentation.

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