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  • Anthem Claim Action Request Form

Get Anthem Claim Action Request Form

: Zip: Claim Information Patient Name: Patient ID #: (include prefix or suffix if applicable) Claim Number(s): Date(s) of Service: Billed Amount: Process Date: Action Requested (Include a copy of the remittance notice and a corrected claim if necessary) -Authorization/Referral # -Billed/Allowed amount (attach copy of manufacturer s invoice)** -COB -Date of Service -Denied as Duplicate -Diagnosis Code** -Number of Units -Patient Responsibility** -Place of Service -Procedure Code/Modifier**.

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5 Easy Steps To Achieve Clean Claim Submission Rate Ensure patient information is correct. ... Follow a stringent prior authorization process. ... Follow the latest medical coding guidelines. ... Make sure the right modifiers are used. ... Perform quality checks prior to claims submissions.

Reasons for Anthem insurance claims denials include: The filing deadline has expired. The insured mad a late payment to COBRA. The medical device or treatment sought is not medically necessary.

Claims 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.

You can also file a grievance by: Calling Member Services at 844-912-0938 (TTY 711). Logging into the secure member portal or the mobile app and finding Grievances under Support. Printing the form and emailing it to ohioga@anthem.com or faxing it to us at 866-587-3316.

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).

Whether you are viewing a claim for yourself or a family member, you can review all claims at your Anthem member account. Log in to your member account to access your claims information.

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.

How To Submit An Anthem Claim Yourself Make sure the claim form from your benefits plan includes all required information, especially procedure codes (you can receive these from your doctor's office). If you're filling the form out by hand, write legibly. File your paperwork promptly and within the time limit.

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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
Anthem Claim Action Request Form
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