How to File an Appeal Involving a Non-Urgent Request or Claim Sample Clauses

How to File an Appeal Involving a Non-Urgent Request or Claim. In the case of an appeal involving a non-urgent request or claim, you must submit your request in writing to the following address: Appeal Coordinator — Customer Service Department Blue Cross and Blue Shield of Oklahoma P. O. Box 3283 Tulsa, Oklahoma 74102-3283 The written request should include the name of the Covered Person, the Covered Person identification number, the nature of the complaint, the facts upon which the complaint is based, and the resolution you are seeking. Necessary facts are: dates and places of services, names of Providers of services, place of hospitalization and types of services or procedures received (if applicable). You should include any documentation, including medical records that you want to become a part of the review file. The Plan Administrator may request further information if necessary.
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Related to How to File an Appeal Involving a Non-Urgent Request or Claim

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