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Urine Drug Test (UDT) Inquiry Form

For Out-of-Network Providers

This form is for out-of-network (non-contracted) providers to submit inquiries regarding Urine Drug Testing (UDT) claim determinations. In-network providers should not submit inquiries via this form and instead should contact their network representative with any inquiries.

Do not use this form to submit appeals or requests for reconsideration. Submission of this form does not constitute an appeal on behalf of a member. To submit an appeal on behalf of a member, consult the terms of the member’s benefit plan.

Acknowledgment of Online Content & Link Review

Prior to completing this form and submitting, please ensure that you have reviewed the online information and Urine Drug Testing Documentation Guidelines regarding properly submitting a Urine Drug Test (UDT) claim.

Have you reviewed the online information links regarding documentation on properly submitting a Urine Drug Test (UDT) claim? * (required)

Yes No

Out-of-Network Status Confirmation *

Please check to confirm that this inquiry is from an out-of-network provider

In-network providers should contact their network representative with any inquiries

Provider Location Information

Provider Name:*

National Provider Identifier (NPI):*

Laboratory Location (State):*

State Where Claims are Submitted:*

Provider Contact Information

Email Address:*

Phone Number:

Additional Provider Information

Do you file claims with Blue Cross Blue Shield of (Mark all that Apply):*

BCBSIL (Illinois)

BCBSMT (Montana)

BCBSNM (New Mexico)

BCBSOK (Oklahoma)

BCBSTX (Texas)

BCBS of another state

If you selected "Blue Cross Blue Shield of another state," which state(s)?

Provider Inquiry

Claim Reference Number (DCN):*
20 digit alphanumeric starting with "0000"

Specific Inquiry:*
Not to be used for General Claim inquiries

Click on Icon to Submit

Disclaimer: This form is not to be used for claim inquiry status, appeal reconsideration or In-Network inquiries. Prior to completing this form and submitting, please ensure that you have reviewed the online information and links regarding documentation on properly submitting a Urine Drug Test (UDT) claim. Please do not include attachments.