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42 11/2005
• (888) 883-2720 for vendor supported sites.
• (800) 638-9677 for Network Plus customers.
Requests for Clinical Information
On the following page is a standard cover sheet for submitting clinical information
when filing an initial paper claim. Using this cover sheet will help ensure that
documentation is “attached” to the right claim(s) and will expedite processing.
You may also use this form when you know in advance that BCBSGa requires
clinical information (such as an unlisted procedure code).
If you have received a request for clinical information and if you have the claim
number, you may also use this form to submit supporting documentation. VERY
IMPORTANT NOTE: If BCBSGa has requested clinical information, please follow the
instructions in the request/letter and attach a copy of the request/letter as the
cover sheet. The bar coding helps to expedite processing!
YOU CAN FAX (IF LESS THAN 25 PAGES) OR MAIL YOUR COVER SHEET AND
INFORMATION TO:
Blue Cross Blue Shield of Georgia
2357 Warm Springs Road
Columbus, GA 31904
Fax: 1-877-868-7950
Clinical Submission Categories
The following is a list of claims categories where we may routinely require submission
of Clinical Information before or after payment of a claim:
• Claims involving pre-certification/prior authorization/pre-determination (or
some other form of utilization review including but not limited to:
• Claims pending for lack of precertification or prior authorization
• Claims involving Medical Necessity or Experimental/ Investigative
determinations
• Claims for pharmaceuticals requiring prior authorization.
• Claims involving certain modifiers, including but not limited to Modifier 22.