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Make edits, fill in missing information, and update formatting in US Legal Forms—just like you would in MS Word.

Download a copy, print it, send it by email, or mail it via USPS—whatever works best for your next step.

Sign and collect signatures with our SignNow integration. Send to multiple recipients, set reminders, and more. Go Premium to unlock E-Sign.

If this form requires notarization, complete it online through a secure video call—no need to meet a notary in person or wait for an appointment.

We protect your documents and personal data by following strict security and privacy standards.
You can file a dispute for an item only one time. Any duplicate requests will be reviewed as an appeal to the original dispute request and will follow the appeal process. If you initiated the return or refund, you can't dispute the charges. If the item is listed with Keep It Rules, you can't dispute the charges.
If you see unauthorized transactions, please promptly contact the financial institution that issued your card. Typically, there is a customer service number for your financial institution listed on the back of the card or on your billing statement.
If you think we have made a mistake in denying your medical service, or if you don't agree with our decision, you can ask for an appeal. You must do this within 60 calendar days from the date on the Notice of Action sent to you. We will resolve your concerns within 30 days of receiving your complaint.
You may submit a grievance to Blue Shield by calling (800) 393-6130, going online at blueshieldca, or by mailing your written grievance to Blue Shield of California, Appeals and Grievances Dept, P.O. Box 5588, El Dorado Hills, CA 95762.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
When complete, please mail to: Attn: Grievance and Appeals Department, Anthem Blue Cross, P.O. Box 60007, Los Angeles, CA 90060-0007. For claim disputes, please use the Provider Dispute Resolution form. This information is part of the permanent record. Write clearly and legibly.
You have the right to voice your dissatisfaction with any aspect of Anthem' services for investigation and resolution by: Writing your grievance. Completing the online GRIEVANCE FORM. Calling our Customer Care Center at 800-407-4627 (TTY 711) Monday to Friday, 7 a.m. to 7 p.m. Pacific time.
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.
How to Find Timely Filing Limits With Insurance Insurance CompanyTimely Filing Limit (From the date of service) Anthem California 90 Days BCBS Illinois 180 Days Beacon Health 90 Days Blue Cross of California 180 Days28 more rows