Performance Manager
BIDCO Member Appeals
  Today's Date:
   
  Member Information  
 
First Name:
 
Last Name:
 
Date of Birth:
 
Telephone:
 
Address:
 
City:
 
State:
 
ZIP:
 
e-Mail:
   
  Primary Care Provider Information  
 
Provider First Name:
 
Provider Last Name:
 
Provider Address:
 
Provider City:
 
Provider State:
 
Provider ZIP:
 
Provider Telephone:
   
  Health Plan Information  
 
Insurance Name:
Blue Cross Blue Shield
Harvard Pilgrim Health Care
Tufts Health Plan
 
Subscriber ID:
 
Primary Insured Member Name:
   
  Appeal Information  
 
Reason for Appeal:
Referral restrictions made by PCP or by BIDCO
Type or intensity of treatment or services prescribed by PCP
Timely access to treatment or services prescribed by PCP
Other
 
If "Other" please describe:
 
Please describe the issue you are appealing in detail (limit of 3,000 characters):
   
  Follow-up  
  Please indicate the best time to reach you (check all that apply):  
 
8:00 AM to 11:00 AM
  11:00 AM to 2:00 PM
  2:00 PM to 5:00 PM
  Please indicate the best method of contact (check all that apply):  
 
Telephone
  e-Mail
   
 
 
  Attestation: By checking this box, and typing my name below, I attest that the information contained in this document is true and correct to the best of my knowledge.
  Signature:
  Are you the patient? Yes
No
  If "no", please fill out the following section.  
 
 
   
  Authorized Representative Information  
 
Representative First Name:
 
Representative Last Name:
 
Representative Relationship:
Spouse/Partner
Other Family Member
Attorney
Legal Guardian
Friend
 
Representative Address:
 
Representative City:
 
Representative State:
 
Representative ZIP:
 
Representative Phone:
  Questions?

Call (617) 754-1000, Option "5" or visit www.bidco.org/infoforpatients/appeals

 
          



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