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July 2016

Use Medical Record Routing Form as cover sheet when sending medical records to Blue Cross

When sending records to us, it’s important to fill out the Medical Record Routing Form and use it as your cover sheet. This applies to:

  • Medical records we’ve requested from you
  • Supporting medical records you’re sending to us as part of a request to review a rejected claim

Instructions for filling out the form online are included with it on web-DENIS. Once we receive the completed form with the records, all of the documents are scanned into our repository. Then the department responsible for reviewing the claim and documentation is notified that the records have been received.

Allow 30 days for medical record reviews.

For BlueCard® claims, the completed form and medical records should only be submitted if you received a BlueCard claim rejection requesting the records.

Below are some tips to ensure your records are reviewed promptly:

Follow these guidelines

  • Fill out the Medical Record Routing Form on web-DENIS, print it and use it as your cover sheet.
  • Fax the routing form and medical records totaling 100 pages or fewer to 1-866-617-9917.  Medical record documentation more than 100 pages should be mailed to us at the address on the bottom of the form.
  • Contact our Provider Inquiry staff if you have questions on a medical record request or to find out the status of your records review if you haven’t received a response to the claim after 30 days.

Avoid these missteps

  • Don’t attach a paper claim form to the Medical Record Routing Form with your records.
  • Don’t attach multiple records for different claims or patients to a single routing form.
  • Don’t copy the form and complete it by manually writing in the required information.

The Medical Record Routing Form can be found under the Frequently Used Forms section of web-DENIS. Follow these steps:

  1. Go to bcbsm.com.
  2. Log in as a provider.
  3. Click on web-DENIS.
  4. Click on BCBSM Provider Publications and Resources.
  5. Click on Newsletters and Resources.
  6. Click on the Frequency Used Forms section in the upper right corner of the page.
  7. Choose Medical Records Routing Form.
No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.