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  • New Hampshire Referral Form - Anthem

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New Hampshire Referral Form 1 2 Date 2a. Patient Name 2b. Name of Insurance Carrier ? HMO ? POS ? Other 2c. Patient Insurance ID # 2d. Patient DOB 2g. ? Emergent (within 48 hours) 2e. Reason for Referral.

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Write an opening paragraph. You will want to establish the purpose of your letter in the first paragraph. This paragraph is not the place to get into the details. Briefly explain what decision or action you are appealing, give the name of the person who made the decision, and the date on which it was made.

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.

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.

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.

Dear [Contact Name/Medical Director]: I am writing to request that you reconsider your denial of coverage for [DRUG NAME], which I have prescribed for my patient, [Patient First and Last Name]. Your reason(s) for the denial [is/are] [list reason(s) for the denial].

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.

What is a referral? A referral is when your primary care provider (PCP) sends you to another provider, like a specialist, for care. As an Anthem HealthKeepers Plus member, you don't need a referral to see a provider who's not your PCP as long as the provider is listed as one of the doctors in your plan.

If you have questions about this form or need additional assistance, contact Provider Services at (844) 396-2330 or contact your local Provider Experience Consultant.

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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
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
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:
+1 833 426 79 33
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