Get Anthem Provider Maintenance Form

Completing the Anthem Provider Maintenance Form online is essential for providers looking to update their information effectively. This guide provides detailed, step-by-step instructions to ensure a smooth process for all users.

Follow the steps to fill out the Anthem Provider Maintenance Form online

1. Click ‘Get Form’ button to access the Anthem Provider Maintenance Form and open it in your preferred editing platform.
2. Begin with Section A, providing general information. Enter your tax identification number in the Practice Tax ID Number field if making changes. Specify details of any changes in Section K.
3. In Section B, indicate the reason for submitting the form. Choose the effective date for the change, which must be a future date, and check the relevant boxes for actions being taken, adding further details in Section K as necessary.
4. Proceed to Section C, where you will input provider information. For changes affecting the entire group, list the group name in the Provider First Name field, entering 'N/A' for the Last Name and Title fields.
5. If adding a new provider, a separate form must be completed for each new addition, including their CAQH number in Section C.
6. In Section D, autism providers should enter their professional license number in the designated field.
7. Move to Section E for practice address details. Make sure to include the required zip code and indicate the office hours. Provide the practice's fax number and email, and mark the option if the billing address is the same as the practice address.
8. If changing the address in Section F, fill in the NPI field appropriately. If multiple NPIs exist, only include the one you will bill with to avoid unnecessary setups.
9. Lastly, utilize Section K for additional comments that will assist in processing your request. Ensure all sections are complete before proceeding.
10. After filling out the form, remember to save changes, then download, print, or share the form as needed.

Complete your Anthem Provider Maintenance Form online today to ensure a seamless update process.