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 > Colorado > 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:       |

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**Any other disputes should be done on the regular Claim Action Request form or Provider Dispute Resolution form**

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