Provider Request for Grievance or Appeal
For Commercial and Safety Net (Blue Choice Option, HMOBlue Option, Premier Option,
Premier Child Health Plus and Child Health Plus) products
Please mail this form and medical records/supporting documentation to the
Excellus BCBS Advocate Unit, PO Box 4717, Syracuse, NY 13221
If an appeal is urgent, please fax to 1-315-671-6656.
PLEASE USE BLACK PEN TO COMPLETE THIS FORM. DO NOT USE HIGHLIGHTER,
AS IT WILL NOT BE CAPTURED WHEN DOCUMENT IS SCANNED.
 Request for Grievance: A grievance is a contractual denial or dispute of payment.
Denied claim due to no authorization obtained, contract exclusion, clinical editing (if dispute
process was already followed), not a covered benefit, etc.) Please attach medical records and any
other pertinent information related to the grievance to this form.
 Request for Appeal: An appeal is a denial for pre or post services. It is a denial that
involves not medically necessary or experimental/ investigational. Please attach medical records
and any other pertinent information related to the appeal to this form.
 Urgent Request:  Yes  No (If appeal is urgent, please fax to 1-315 671-6656.)

Grievance Request Date:
(MM/DD/YYYY)
Appeal Request Date:
(MM/DD/YYYY)
An initial review has been completed:  Yes  No
Provider Name:
NPI:
Tax ID:
Provider Office Contact Information
Name:_________________________________________________________________________________________
Office Address:_________________________________________________________________________________
Billing Address:_________________________________________________________________________________
Phone:_________________________________________ Fax: __________________________________________
Email:_________________________________________________________________________________________
Member Information
Name:_________________________________________________________________________________________
Subscriber ID Number (include prefix):_______________________
Date of Birth (MM/DD/YYYY): _____________________
Date of Service:
(MM/DD/YYYY)
Claim/Authorization Number(s):
If a claim, which type: (check one)
 CMS-1500  UB04
Procedure Code(s):
Comments:
B-5178
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