Get Medical Claim Form And Instructions - Anthem

This guide provides comprehensive instructions on how to accurately complete the Medical Claim Form And Instructions - Anthem online. Follow these steps to ensure your claim is filed correctly and efficiently.

Follow the steps to successfully fill out your claim form.

1. Click ‘Get Form’ button to access the Medical Claim Form And Instructions - Anthem and open it in your document editor.
2. Enter your subscriber number in the designated field. This number is crucial for identifying your insurance coverage.
3. Fill in the group number associated with your insurance plan.
4. Clearly print the patient's name in the specified format (Last, First, Initial). This ensures there are no errors in identifying the individual filing the claim.
5. Complete the patient’s birthdate by entering the month, day, and year in their respective fields.
6. Indicate the patient's sex by selecting either male or female.
7. Specify the patient’s relationship to the subscriber by selecting one of the options: self, spouse, child, or other.
8. Provide the subscriber's name in the same format as the patient’s name.
9. Input the subscriber's address, ensuring to include the street, city, state, and zip code.
10. For coordination of benefits, answer the questions provided and complete any additional fields as prompted.
11. If applicable, provide details pertaining to any accidents, including employer name and address, compensation carrier, and dates of accident.
12. State any other group health benefit plans the patient may be covered by and provide insurance company details if necessary.
13. Indicate eligibility for Medicare Parts A and/or B, if relevant.
14. List the illness or symptoms using the diagnosis code from your itemized statement necessary for reimbursement.
15. Input the name of the healthcare provider who rendered the service to the patient.
16. If the service was provided in a hospital, detail the name of the hospital facility.
17. Designate a contact person who Anthem can reach out to if further information is needed, along with a phone number.
18. For each itemized bill, list the date of service, place of service, total charges requested for payment, charge for service, and a brief description of the services received.
19. Ensure you certify the accuracy of all reported information by signing and dating the form.
20. Review the completed form to ensure no fields are left unanswered, as incomplete forms can delay processing. Save your changes, then download, print, or share the form.

Complete your Medical Claim Form And Instructions - Anthem online to ensure timely processing of your claim.