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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How to fill out the Fax Form - Anthem online
This guide provides users with clear, step-by-step instructions on how to complete the Fax Form - Anthem for prior authorization. Following these instructions will facilitate a smooth submission process.
Follow the steps to fill out the Fax Form - Anthem
- Press the ‘Get Form’ button to acquire the Fax Form - Anthem and open it in your document editor.
- Begin by entering the patient information. Include the patient's name, ID number, date of birth, phone number, and email address in the designated fields.
- Fill out the physician information section. Enter the prescribing physician's name, address, phone number, fax number, specialty, DEA number, and NPI number.
- Indicate the medication being prescribed by checking the box for ( extended release-injectable) under the medication section.
- Provide details related to the strength of the medication by filling in the quantity per 30 days.
- Clearly state the diagnosis in the provided section. Ensure that this information accurately reflects the patient's condition.
- Review the approval criteria and check all boxes that apply based on the patient's treatment. Be attentive to ensure that all required fields are completed accurately.
- Include the physician's signature in the signature section provided, along with the date of signing.
- Once all sections are completed and reviewed for accuracy, save your changes. You can then print, download, or share the form as required.
Complete your Fax Form - Anthem online now for a seamless submission process.
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Get answers to your most pressing questions about US Legal Forms API.
What is the number for Anthem HealthKeepers Plus Virginia?
Are you experiencing a behavioral health crisis? Call our Behavioral Health Crisis Line at 1-844-429-9620 (TTY 711) if you or a family member are having a mental health or substance use crisis. We're here to help anytime, day or night.
What is the fax number for Anthem BCBS CA?
Please fill out the Prescription Drug Prior Authorization Or Step Therapy Exception Request Form and fax it to (844) 474-3347.
What is the phone number for Anthem BCBS of Virginia provider claims?
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.
What is the fax number for Anthem BCBS of Virginia claims?
Fax: 1-800-964-3627.
How do I contact Anthem VA provider?
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.
What is the fax number for Anthem CA provider?
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.
Is Anthem the same as Blue Cross Blue Shield in Virginia?
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.
How do I submit an online claim to Anthem?
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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