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  • Provider Dispute Resolution Form - Anthem

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Provider Dispute Resolution Form Date (mm/dd/yyyy): Requestor Information Provider Name: Provider # or TIN: Office or Practice Name: Contact Name: Signature: Telephone: Fax: Address: City: State:.

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How long do I have to submit a Level I Provider Appeal? Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Billing/Coding Dispute. Providers will have 90 calendar days from the claim adjudication date to submit a Level I Provider Medical Necessity Appeal.

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. Select Dispute the Claim to begin this process.

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.

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.

Clear Claim Connection is located on the Availity Portal. Log into Availity.com. Once logged in, select Payer Spaces, and choose the Anthem icon. Under Applications, select Clear Claim Connection.

If you need assistance, please call Provider Services at 844-396-2330. You can call Monday through Friday from 8 a.m. to 5 p.m. PT.

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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