Get Anthem Claim Action Request Form 2011-2026

Filling out the Anthem Claim Action Request Form online is an essential step in submitting your claims efficiently. This guide provides clear, step-by-step instructions to help you navigate each section of the form with ease.

Follow the steps to complete the form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of the request in the format mm/dd/yyyy. This date is crucial for tracking the submission.
3. Fill in the requestor information, including the provider's name, provider's TIN, and the office or practice name associated with the claim.
4. Provide the contact name and the National Provider Identifier (NPI) for accurate identification.
5. Complete the contact information, including telephone number, fax number, and address fields, ensuring all details are correct.
6. In the claim information section, input the patient's name and patient ID number, making sure to include any relevant prefixes or suffixes.
7. Input the claim number, date(s) of service, billed amount, and process date to provide context for the request.
8. Under action requested, clearly specify your request. Attach the remittance notice and any necessary corrected claims.
9. Enter details such as authorization/referral number, billed/allowed amount, and include any required documentation for substantiation.
10. Complete all applicable sections including diagnosis code, number of units, patient responsibility, place of service, and procedure code/modifier.
11. If needed, use the 'Other' section to provide any additional explanations related to your request.
12. Once all required fields are completed, review your entries for accuracy before saving your changes, downloading, printing, or sharing the form.

Complete your documents online today and streamline your claims process.