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  • Anthem Midwest Provider Inquiry/refund/adjustment Form

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ANTHEM MIDWEST PROVIDER INQUIRY/REFUND/ADJUSTMENT FORM Date: Underpayment Overpayment Corrected Claim Unknown Type of InquiryPhysician Facility Dental Vision Identification Number Member Name Patients.

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The appeal must be received by Anthem Blue Cross (Anthem) within 365 days from the date on the notice of the letter advising of the action.

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.

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.

We'll send you an acknowledgement letter within three business days after we get your appeal. The letter will tell you we got your appeal request. You can also ask for an appeal by calling Member Services at 1-866-408-6131 (TTY 711).

What do I include with my appeal? If your appeal is about a Part D drug: Your completed Redetermination Request Form. Your name, address and member ID number. Your reasons for appealing. Any information or evidence (documents, medical records) to support your appeal.

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.

Care Management support is available 24/7 through Anthem Blue Cross Cal MediConnect Plan Customer Care at 1-855-817-5786.

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© Copyright 1997-2025
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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
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
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