Submit your completed claim form along with the required itemized bill to Anthem Blue Cross at P.O. Box 1407, Church Street Station, New York, NY 10008-1407. If you prefer electronic submission, visit anthembluecross.com for secure online processing options. For additional assistance, contact the Member Services number listed on your ID card for guidance.

For 2024, ensure that you submit your claims within the specified deadlines mentioned in your insurance policy. In 2025, keep track of any updates or changes to the insurance claims process. It’s crucial to act quickly to avoid delays in receiving your benefits.

The purpose of this form is to allow members to submit claims for medical services rendered by healthcare providers. It ensures that the necessary information is shared with the insurance company for processing. This claim form serves as a formal request for reimbursement of eligible medical expenses incurred by the insured party.

• 1. Member Information: Collects details about the member submitting the claim.
• 2. Patient Information: Captures data about the patient receiving medical services.
• 3. Diagnosis: Requires a description of the illness or injury.
• 4. Work-related: Inquires if the condition is work-related and requires employer details.
• 5. Other Insurance: Seeks information about additional health insurance coverage if applicable.
• 6. Medicare: Checks for Medicare coverage details and requires relevant policy information.
• 7. Authorization and Signature: Requires signatures from the patient or authorized representative to process the claim.

Failure to submit this form may result in delays or denial of your claim for benefits. Without proper documentation, the insurance company cannot process requests for reimbursement. Ensure all required fields are filled out accurately to avoid complications.

• Claim Denial: If the form is not submitted correctly, your claim may be denied.
• Delay in Processing: Incomplete submissions can lead to significant delays in receiving your benefits.
• Lost Documentation: Failure to attach necessary documents can result in misunderstandings.

• 1. After Medical Treatment: Use this form immediately after receiving treatment to ensure timely reimbursement.
• 2. When Provider Doesn't File Claim: Utilize this claim form when your provider fails to submit the claim for services.
• 3. For Multiple Insurances: Necessary for individuals with more than one insurance provider to claim benefits.