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  • Anthem Policy Upgrade Application Form

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Instructions 1. 2. 3. 4. 5. Print clearly and complete this application in ink. For each person to be covered, provide all requested information. Sign and date any additional attachments. Primary.

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Contact support

Where can an appeal be filed? 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.

The Provider Maintenance Form (PMF) is an online form used to request changes to existing practice profiles of Kentucky physicians, practitioners, professionals and ancillary professional providers with Anthem.

Claim payment reconsideration. This is the first step and must be completed within 60 calendar days of the date of the provider's remittance advice.

How to file an appeal Written: MHS Appeals, P.O. Box 441567, Indianapolis, IN 46244. Phone: MHS Member Services or MHS Appeals at 1-877-647-4848 (TTY: 1-800-743-3333) Fax: 1-866-714-7993. Email: appeals@mhsindiana.com.

Anthem will allow separate reimbursement for E&Ms performed on the same day of a major surgery (90-day global period) or minor surgery (0-day or 10-day global period) when billed with a modifier 25.

What do I include with my appeal? If your appeal is about a Part D drug: Your completed Redetermination Request Form. Your name, address and member ID number. Your reasons for appealing. Any information or evidence (documents, medical records) to support your appeal.

We'll send you an acknowledgement letter within three business days after we get your appeal. The letter will tell you we got your appeal request. You can also ask for an appeal by calling Member Services at 1-866-408-6131 (TTY 711).

The request must be submitted within 60 calendar days of notification of claim payment or denial. The date of notification is considered to be the date on the most recent RA for the claim.

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© Copyright 1997-2025
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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