[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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