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N of Benefits Center at (800) 601- 4829 1. PATIENT INFORMATION 2. PHYSICIAN INFORMATION Patient Name: Prescribing Physician: Patient ID #: Physician Address: Physician Phone #: Physician Fax #: Physician Specialty: Physician DEA: Physician NPI #:.

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Please fill out the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form and fax it to (844) 474-3347.

By Phone: Call the number on the back of the member's ID card or dial 800-676-BLUE (2583) to speak to a Provider Service representative.

Fax: 1-800-964-3627.

Thank you. 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.

Hours: Monday to Friday, 8 a.m. to 5 p.m. Behavioral Health: For prior authorization requests specific to behavioral health, please fax requests to 1-855-473-7902 or email Medi-calBHUM@wellpoint.com.

In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc. trades as Anthem HealthKeepers providing HMO coverage, and their service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123.

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.

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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