Blue Card Appeal Request Form

This form is to be used to request a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted.

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* Required Field

Enter Patient Information

  • Patient ID Number:
    (include Alpha Prefix)*
  • Patient Account Number: *
  • Patient First Name: *
  • Patient Middle Initial:
  • Patient Last Name: *
  • Date(s) of Service: *
  • Group ID: *

* Required Field

Enter Provider Information

  • Provider ID: *
  • Provider Name:
  • Contact First Name:
  • Contact Last Name:
  • Contact Email Address:
  • Contact Phone Number: *
  • Enter a 10 digit phone number.
  • Contact Phone Ext:
  • Contact Fax Number: *
  • Enter a 10 digit phone number.

Date of Appeal Request:

Please enter Blue KC Claim ID Number(s): *:

Please explain the reason for the Appeal Request (please note: Appeals are for medical necessity only. All other inquiries for denials must be submitted on an inquiry form)*

Please explain the supporting documentation your are submitting as part of this appeal. *

Please attach supporting documentation:*

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 817-3381.

Cancel

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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