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  • Agent Acknowledgement Form - Anthem

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You with the purchase of your Anthem Blue Cross and Blue Shield individual coverage. So that we may use your application and still acknowledge your broker s assistance, you and your broker must complete the information below. Once your broker submits this completed form and your original application to us, the two forms will be attached together and shall constitute your complete application for coverage. The two forms together shall have the same legal effect as if you submitted your origina.

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ICD-9 Code 066 -Other arthropod-borne viral diseases- Codify by AAPC.

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.

and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. (collectively “BCBSGa”) has changed to Anthem Blue Cross and Blue Shield (Anthem), a trusted name that symbolizes quality for millions of consumers across the country. While our trade name and logo have changed, almost everything else will stay the same.

ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Additional information about Anthem Blue Cross and Blue Shield in Ohio is available at .anthem.com.

For all other precertification requests (including all elective inpatient or outpatient services), please fax to: 1-800-964-3627.

You or your provider can request an expedited appeal. Call Member Services toll-free at 844-912-0938 (TTY 711), Monday through Friday from 8 a.m. to 7 p.m. Eastern time. When we receive your call, we will call you within 72 hours to tell you our decision.

This means claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement, and Anthem will refuse payment if submitted more than ninety (90) days after the date of service1. If you have any questions, please contact your local network representative.

For all other precertification requests (including all elective inpatient or outpatient services), please fax to: 1-800-964-3627.

TPA stands for Third Party Administrator and as such is defined as an organization or individual that handles the claims, processing, and reporting components of a self-funded health benefits plan.

You may file an appeal within 60 calendar days of the date on the letter we sent to tell you of our decision.

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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