Get Anthem Overpayment Adjustment Request Form 2012

This guide provides comprehensive instructions on filling out the Anthem Overpayment Adjustment Request Form online. It is designed to help users understand each section and field, ensuring that the submission process is as smooth and efficient as possible.

Follow the steps to complete the Anthem Overpayment Adjustment Request Form online.

1. Press the ‘Get Form’ button to access the Anthem Overpayment Adjustment Request Form and open it in the appropriate online editor.
2. Fill in the date field at the top of the form, indicating the current date when you are submitting the request.
3. Enter your name and contact details in the 'From' section. Make sure to provide complete information to avoid any delays in processing.
4. If applicable, provide your provider ID and phone number, including any extension you may have.
5. In the relevant section, choose your preferred option for recouping or refunding the overpaid amounts. Indicate whether you prefer a credit on a future payment or if you are returning the overpayment.
6. Next, complete the patient’s information by entering their name, medical record number, member ID number, and the dates of service that are related to the overpayment.
7. Fill in the claim number(s) associated with the overpayment, along with the total charges and the amount paid by Anthem.
8. Include any amounts paid by other insurance, if applicable, and the remittance advice payment date.
9. For FEP members, make sure to select the appropriate reason for the refund, such as duplicate payment or charges billed in error.
10. Provide any additional comments or explanations related to the overpayment.
11. At the end of the form, ensure you include the name and address of any other insurance involved.
12. Review all entries for accuracy, then you can save your changes, download the completed form, print it out, or share it as needed.

Complete your Anthem Overpayment Adjustment Request Form online today for a seamless resolution.