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.