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How to fill out the Anthem Claim Action Request Form online
Filling out the Anthem Claim Action Request Form online can streamline the claims process and ensure that your request is accurately submitted. This guide provides clear, step-by-step instructions to help you navigate the form effectively.
Follow the steps to complete your Anthem Claim Action Request Form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling in the requestor information. Provide the provider name, provider number or taxpayer identification number (TIN), office or practice name, contact name, telephone number, fax number, and complete address, including city, state, and zip code.
- Next, move to the claim information section. Input the patient name and patient ID number, including any relevant prefix or suffix. Then, enter the claim number(s), the date(s) of service, the billed amount, and the process date for the claim.
- In the action requested section, indicate the specific request related to the claim. Include any necessary documentation such as the remittance notice and corrected claim, if applicable. Be sure to specify the relevant authorization/referral number, billed/allowed amount (and attach a copy of the manufacturer's invoice), coordination of benefits (COB), date of service, diagnosis code, number of units, patient responsibility, place of service, procedure code/modifier, or any other pertinent information.
- Provide any additional explanation for your request in the designated area. This is where you can detail any supporting information, such as a statement from a physician or medical documentation.
- Finally, review all entered information for accuracy. Once confirmed, you can save changes, download, print, or share the form as needed.
Complete your Anthem Claim Action Request Form online today to ensure timely processing of your claim.
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To submit an international claim to Anthem, begin by collecting all relevant medical documents from your treatment abroad. Complete the Anthem Claim Action Request Form, making sure to include all details about the foreign healthcare services received. After filling out the form, send it along with your international medical bills to the appropriate Anthem address or online submission platform for review.
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