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Highmark bcbs pa provider appeal form

Highmark appeal form pa 2025

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The document is a Medical Claim Form that requires completion by both the employee and the healthcare provider. It collects essential information about the employee, patient, diagnosis, insurance coverage, and details of medical services rendered. The form includes sections for accident involvement, other insurance coverage, and assignment of benefits to providers. It also contains legal disclaimers regarding fraud and privacy laws.

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Versions	Form popularity	Fillable & printable
2003	4.8 Satisfied (141 Votes)
2000	4.3 Satisfied (49 Votes)

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How do I file an appeal in PA?

Once you have filled out the Notice of Appeal, you must file it with the Prothonotary in the Common Pleas Court where the office of the District Justice is located. The Common Pleas Court charges a fee for filing an appeal. The fee varies from county to county but is generally in the $40 - $60 range.

What is the timely filing limit?

You must file your appeal within 60 calendar days from the date on the Notice of Action letter.

What is the timely filing limit for Highmark BCBS of PA appeal?

The expedited appeal must be initiated within 180 days from receipt of the denial notification in all of Highmarks service areas in Delaware, New York, Pennsylvania, and West Virginia. Note: The time frame is within 60 days of receipt of the denial notification for Highmark Healthy Kids (CHIP).

How do I appeal a Highmark provider in PA?

Appeals Call us at: 1-800-685-5209 in Pennsylvania (TTY users: 711) 8 a.m. - 8 p.m. Eastern Time 7 Days a week from October 1 through March 31. Send us a request by fax to: Member, Non-Participating Medicare Provider, and any Pre-Service Appeals: 412-255-4503. Mail in a request to: Highmark Wholecare.

What is the fax number for Highmark appeals?

You may also request a copy of the information used to review your appeal free of charge. In addition, you or your representative have the right to give additional information in person at the time of the appeal hearing, in writing, by phone, or by fax to 1-833-841-8074.

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