[Subject] - Anthem Blue Cross Blue Shield: Health ...



Attach a copy of the original claim form with corrections and/or attachments and send to:

Attn: Claims

Anthem Blue Cross Blue Shield Partnership Plan, Inc.

P.O. Box 37180

Louisville, KY 40233-7180

Corrections or additional information by line number is necessary to reconsider previously paid (overpayment/underpayment) and/or denied claims listed.

Please Print or Type

|Provider Name: |      |

|Address: |      |

|Provider NPI: |      |Tax ID Number: |      |

|License Number: |      |

|Member Name: |      |Client Index Number: |      |

|Claim Type (Please check one.) |

| |Hospital/Inpatient | |LTC/Hospice | |DME/Med Supplies |

| |Hospital/Outpatient | |Physician | |Home Care |

|Remarks: |      |

|      |

|      |

This is to certify that the above information is true, accurate and complete.

| | |      |

|Signature of provider or authorized representative | |Date |

|For Anthem Blue Cross Blue Shield Partnership Plan, Inc. Use Only |

| Reconsideration | Appeal |

|Network Prv: Y N |Orig Claim DCN: |      |Records attached: Y N |

|Prior MRU: Y N |Attached: Y N |

|Prior PA: Y N |Attached: Y N |

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