Claim Support Request Form

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Instructions

For claims status information, please log into MyInsuranceManager. If you would like to request claim support for a processed claim, please complete the form below.

This form requires entry of a 13 digit claim number issued by the member's Health Plan. For clearinghouse or vendor claim responses that did not result in a Health Plan claim number, please contact edi.services@bcbssc.com.

Practice or Facility Information

Practice or Facility Name

Tax ID # (TIN)

Group NPI

Address 1

Address 2

ZIP Code

City

Contact's First Name

Contact's Last Name

Contact's Phone Area Code () First Three Digits - Last Four Digits

Contact's Extension

Contact's Email

Same as Contact

Clinician's First Name

Clinician's Last Name

Same as Group NPI

Clinician's NPI

Outpatient clinics please use same NPI for both fields.

Request Information

Please provide a brief summary of the request Max characters: 250

Refund #

Member Information

First Name

Last Name

Date of Birth

mm/dd/yyyy

ID Card Number

DOS Start

mm/dd/yyyy

DOS End

mm/dd/yyyy

Claim Number

Additional Information Max characters: 250

Companion Benefit Alternatives, Inc.

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