Get Va Anthem 110845 2016-2025

Filling out the VA Anthem 110845 form online can streamline the provider overpayment refund process. This guide offers step-by-step instructions to help you complete each section of the form accurately and efficiently.

Follow the steps to successfully fill out the VA Anthem 110845 form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling in the refund information. Input the date, patient name, provider number, member identification number, provider name, patient account number, provider address, city, state, zip code, claim number, and dates of service. Be sure to provide a valid provider phone number and the amount of the refund check you are requesting.
3. In the refund reason section, check one of the following options that apply to your situation: 'Not our patient', 'Duplicate payment', 'Billed in error', 'Workers’ Comp', 'Paid primary but should be secondary to another insurance carrier', 'Two “Blue” coverages', or 'Other'. If 'Other', provide a brief explanation.
4. Fill out the ' Refund Action Taken' section if applicable; this section is intended for Anthem use only. Leave blank if you are submitting the form for a refund.
5. If you are sending a check or returning a check, ensure you have checked the corresponding box and have provided the necessary mailing addresses indicated in the instructions.
6. Review all fields for accuracy before finalizing your submission. Ensure that all necessary information is complete and correct.
7. Once you have confirmed that all information is correct, save your changes, download, print, or share the completed form as needed.

Complete your VA Anthem 110845 form online to ensure a smoother processing experience.