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  • Anthem Provider Adjustment Form

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ANTHEM BLUE CROSS AND BLUE SHIELD PROVIDER INQUIRY/REFUND/ADJUSTMENT FORM Date Underpayment Overpayment Physician Facility Dental T Identification Number Corrected Claim Member Name Claim No. Patient Name Serv. Date/Adm. Date Provider Tax ID No. Anthem Provider No. Phone No. Provider Name Remit Address Unknown Type of Inquiry Vision NPI Patient Account No. Billed Amount Office Contact Name Fax No. Section 1 Check box that best describes reason fo.

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The corrected claim must be received within the timely filing limit due to the initial claim not being considered a clean claim. Anthem follows the standard of: • For participating providers — within the 180 day timely filing period. For nonparticipating providers — within the 365 day timely filing period.

Call Member Services at 1-855-817-5785 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. This call is free. Fax your written appeal to 1-888-458-1406.

By Phone: Call the number on the back of the member's ID card or dial 800-676-BLUE (2583) to speak to a Provider Service representative.

The appeal must be received by Anthem Blue Cross (Anthem) within 365 days from the date on the notice of the letter advising of the action. Anthem uses Availity, a secure, full-service web portal that offers a claims clearinghouse and real-time transactions at no charge to health care professionals.

Claim dispute From the Availity home page, select Claims & Payments from the top navigation. Select Claim Status Inquiry from the drop-down menu. Submit an inquiry and review the Claims Status Detail page. If the claim is denied or final, there will be an option to dispute the claim.

The appeal must be received by Anthem Blue Cross (Anthem) within 365 days from the date on the notice of the letter advising of the action.

You or your provider can request an expedited appeal. Call Member Services toll-free at 844-912-0938 (TTY 711), Monday through Friday from 8 a.m. to 7 p.m. Eastern time. When we receive your call, we will call you within 72 hours to tell you our decision.

Log in / Create account, so we can use your account information to help you fill out the form faster. To file a grievance for medical or pharmacy services by phone, call the customer care number on your member ID or (800) 393-6130 [TTY 711]. For mental health and substance disorder services, call (877) 263-9952.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232