BLUE CROSS AND BLUE SHIELD
Additional Information Requested form
(Note: this form must be placed on top of any attachments)
This form is available in electronic format for typing your information.
Go to > Providers > Nevada > Provider Home > Download Commonly Requested Forms >
Additional Information Requested form.
This form is intended for Explanation of Benefits (EOB)’s with the message “additional information requested” and the provider has not yet received a written request for this information from Anthem. Please check off what method you have completed to obtain the additional information needed to process your claim. **Please note: without one or more boxes checked below, and the additional information required this form and any corresponding information will be returned to you**
Obtained what “additional information” is needed through one of the following:
–**Customer Service:
Please indicate the Customer Service Phone Number contacted:
Please indicate Reference Number:
–**Secure Messaging through Availity Web Portal:
Please indicate the Secure Messaging ICN number or Reference number:
**Is Additional Information Needed Attached: –Yes or –No
Today’s Date (mm/dd/yyyy):
|Provider Contact Information |
|Provider Name: | |
|Provider # TIN: | |NPI: |
|Office or Practice Name: | |
|Contact Name: | |
|Telephone: | |Fax: |
|Address: | |
|City: |State: |ZIP: |
|Patient / Claim Information (one member and/or claim per form) |
|Patient Name: | |Patient ID #: | |
| | |(Including alpha prefix) | |
|Claim Number: | |Date(s) of Service: | |
|Billed Amount: | |Process Date: | |
|Explain: |
| |
| |
| |
| |
| |
**Any other disputes should be done on the regular Claim Action Request form or Provider Dispute Resolution form**
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