To submit this form, first ensure all required fields are filled out completely. Send the completed form along with any supporting documents to Anthem Blue Cross and Blue Shield, Payment Appeals/Disputes, P.O. Box 61599, Virginia Beach, VA 23466-1599. For faster processing, consider sending via certified mail or fax to the contact number provided in your appeal guidelines.

Please check for important submission deadlines in 2024 and 2025 associated with your claims appeals. Staying informed on timely submissions ensures your appeals are processed without delay. Remember to reference your claim determination letters for specific deadlines.

The purpose of the Claim Payment Appeal Submission Form is to provide healthcare providers with a method to challenge and request a review of payment decisions made by Anthem Blue Cross and Blue Shield. It allows providers to present additional information or clarify circumstances surrounding their claims to potentially secure reimbursement. By completing this form with accurate information, providers can facilitate the review of their claims and engage in a transparent decision-making process.

• 1. Member Information: Includes fields for member's name, date of birth, and ID.
• 2. Provider Information: Captures provider's name, NPI, and contact details.
• 3. Claim Information: Details about the claim, such as claim number and amounts.
• 4. Reason for Appeal: Options to select the reason for the payment dispute.
• 5. Submission Instructions: Provides mailing information for submitting the form.

Failing to submit this form may result in the inability to contest claim decisions, which could lead to financial loss for the provider. It is critical for providers to be aware of the submission deadlines and required information to ensure their appeals are considered. Delays or incomplete submissions may hinder the resolution of payment discrepancies.

• Financial Impact: Providers may lose out on deserved reimbursements.
• Delay in Payments: Failure to appeal may prolong payment issues.
• Loss of Rights: Not submitting the form could mean a forfeiture of the right to dispute.

• 1. When Denied Payment: Use this form to appeal when a payment is denied.
• 2. For Discrepancies: If there are discrepancies in the billed and received amounts.
• 3. Coding Issues: When there are issues regarding claim coding or editing.
• 4. Retroactive Issues: For appeals based on member retro-eligibility problems.
• 5. Experimental Denials: To dispute denials based on experimental or investigational claims.