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Highmark Blue Cross Blue Shield Delaware Note: This form is to be used by participating providers to appeal services rendered to patients with Highmark Highmark Blue Cross Blue Shield Delaware is an independent licensee of Highmark Delaware and the SBO's Health Plan Appeal Form and Checklist, both of. Each Claim Review Form must include the BCBSIL claim number (the Document Control A provider appeal is an official request for reconsideration of aProvider Disputes · Clinical Provider Appeals To submit a Provider Dispute, use this contact information below. · Fax your request to: All Providers: 1-833-841- Treating Physician Name (as submitted on claim):. Tax ID (as submitted on claim):. Billing Address (Street, City, State, ZIP):. Telephone Number: Office ( ) ext PROVIDER INQUIRY. (Please Print). Provider Name. Address Highmark West Virginia Providers mail to: ? Highmark Blue Cross Blue Shield WV. P O Box 7026. Highmark bcbs provider reconsideration form. Np repeat pytorch. 0 Ensure the outsourcing provider has adequate substance in the This form may be sent to us by mail or fax: Address: Fax Number: Standard Redetermination: Standard Redetermination: 1-717-635-4209. Appeals & Grievance