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Get VA Anthem Form 151 2014-2024

Claim Information/Adjustment Request 151 Form Please Mail Form To P. O. Box 27401 Richmond VA 23279-7401 For Federal Employee Program use P. O. Box 105557 Atlanta GA 30348-5557 Provider Please complete all sections of this form to assist us when researching your inquiry/adjustment request. Insured s ID Number Claim Filed Paper as shown on Patient s ID card Claim Type Professional Patient s Name Electronic Patient s Account Number Facility Date Sent Dental Other Insurance if applicable to inquiry Claim Number Charge Please Return To Insurance Company Name Telephone Number Policy Number Effective Date Name of Referring Physician Provider s Name and Address Certification Number Dates of Service Home Other Inpatient Hospital Office Place of Treatment PLEASE DESCRIBE Outpatient Hospital Group Name or Number Reason Additional Information Attached Adjustment Request Overpayment Other Explain Underpayment Onset Date // Check Appropriate Box Consult Date // LMP Accident Illness first symptom 837 Attachment Control Number Briefly Describe Claim Issue and Action Required For Internal Use Only Reply Date Name Inquiry Number 710039 01/2014 In Virginia Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia Inc. serving Virginia excluding the city of Fairfax the town of Vienna and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers Inc* are independent licensees of the Blue Cross and Blue Shield Association* 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*. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers Inc* are independent licensees of the Blue Cross and Blue Shield Association* 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*. .

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