Forms

Any of the forms below should be mailed or faxed to:

BlueCross BlueShield of Tennessee
Attn: BlueAdvantage Operations Appeals/Grievance Coordinator
P.O. Box 180205
Chattanooga, TN 37402
Fax: (423) 296-5498

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• Claim Form (0.3 MB)
  The majority of your claims will be submitted by your provider or pharmacy electronically, but should you need to file a paper claim, please use this form.
• Grievance Form (0.1 MB)
  Use this form to file a complaint about plan policies or procedures
• Appeals Form (0.1 MB)
  Use this form to file a complaint regarding denial of a claim or service.
• Prescription Drug Coverage Determination Form (0.03 MB)
  Use this form to request a formulary exception, tiering exception, a prior authorization or reimbursement for a covered prescription drug claim.

Prior Authorization Forms
Use the appropriate form below to request prior authorization for the services listed below. These forms should be completed by your doctor.

• Skilled Nursing Facility / Inpatient Rehabilitation (0.2 MB)
• Home Health Services (0.05 MB)
• Home Infusion Therapy (0.2 MB)
• Durable Medical Equipment (0.1 MB)
• Outpatient Therapy (0.1 MB)