The parties may agree to a different performance. This is called an accord. When the accord is performed, this is called an accord and satisfaction. The original obligation is discharged. In order for there to be an accord and satisfaction, there must be a bona fide dispute; an agreement to settle the dispute; and the performance of the agreement. An example would be settlement of a lawsuit for breach of contract. The parties might settle for less than the amount called for under the contract.
Anthem Claim Dispute Form With Decimals In Phoenix
State:
Multi-State
City:
Phoenix
Control #:
US-00435BG
Format:
Word;
Rich Text
Instant download
Description
Form popularity
FAQ
One redetermination form can be submitted for multiple claims only for denials by the Unified Program Integrity Contractor or Medical Review probe reviews. Fax request to 1-888-541-3829.
After you fill out the form, Mail/Fax/deliver your request for a hearing within 33 days of the date of the notice you are appealing. Mail: FSSA Document Center PO Box 1810 Marion, Indiana 46952 Fax: 1-800-403-0864 Visit your local DFR/Medicaid Office.
You can also fax to 855-516-1083. Please be sure to mark "EXPEDITED" on the form before faxing.
Please fax to 1-855-516-1083. You may ask us to rush your appeal if your health needs it. We'll let you know we got your appeal within 24 hours from the time we received it.
File the appeal within ten (10) days from the date your "Determination of Eligibility" was sent by one of these methods: Mail the appeal to 10 North Senate Avenue, Indianapolis, IN 46204; Fax the appeal to (317) 233-6888; Deliver the appeal in person to the Department at 10 N.
Claim forms are available by logging into the member website at blueshieldca or by contacting the benefit administrator. Please submit your claim form and medical records within one year of the service date.
Original (or initial) Medi-Cal claims must be received by the California MMIS FI within six months following the month in which services were rendered. This requirement is referred to as the six-month billing limit.
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.
Members have up to 180 calendar days from the date of an incident or dispute, or from the date the member receives a denial letter, to submit a grievance or appeal to Anthem Blue Cross.
Anthem follows the standard of: • 90 days for participating providers and facilities. 15 months for nonparticipating providers and facilities.
More info
Use Availity to submit claims, check the status of all your claims, appeal a claim decision and much more. Please be complete in providing the necessary information, such as provider name and Tax ID, member name and ID. • Access to the form is available on anthem.Provider Dispute Resolution Processes, Provider Dispute Forms, Medicare Advantage Claim Reconsideration Process, How to request reconsideration.
