Follow the steps to successfully complete your form.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by selecting the type of inquiry: underpayment, overpayment, or corrected claim. Check the box that best describes the reason for your adjustment.
3. Fill in the identification number, indicating whether it pertains to a physician, facility, dental, or vision claim. This should include the subscriber's 12-digit identification number.
4. Enter the member's name, which is the name of the policyholder, followed by the patient's name who received the services.
5. Provide the patient account number and the claim number as listed on Anthem's payment voucher.
6. Input the service date or admission date, as well as the billed amount reflecting total charges for the services rendered.
7. Enter the provider tax ID number, Anthem provider number, and National Provider Identifier (NPI). Ensure accuracy with these identification numbers.
8. Include your contact information: the name of the person completing the form, along with their phone number for follow-up.
9. In Section 1, check boxes to indicate the specific reasons for adjustment, such as late charges, duplicate payments, or diagnosis changes.
10. Move to Section 2 to add, delete, or replace charges. Specify each date of service, CPT/revenue code, and line charge. Use the second page if needed.
11. Review your entries for accuracy. If necessary, add any additional comments in the space provided.
12. Once completed, save your changes, and choose to download, print, or share the form as needed.

Complete your Anthem provider inquiry refund adjustment form online today to ensure your adjustments are processed efficiently.