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Click ‘Get Form’ to open the anthem claims action request form in the editor.
Begin by entering the date in the specified format (mm/dd/yyyy) at the top of the form.
In the Requestor Information section, fill in your Provider Name, Provider # or TIN, and Office or Practice Name. Ensure that all contact details, including Telephone and Fax numbers, are accurate.
Complete the Claim Information section by providing the Patient Name and Patient ID #. Include any relevant Claim Numbers and Dates of Service.
Specify the Action Requested by selecting from options such as Authorization/Referral # or Denied as Duplicate. Attach any necessary documentation like remittance notices or corrected claims.
If required, provide additional information that substantiates your request in the Explain section, ensuring clarity for processing.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

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Is Anthem the same as Anthem Blue Cross?

Written reconsiderations To submit a written reconsideration, use a blank Claim Information/Adjustment Request 151 Form, available online at Claims Forms. Once the form is complete, attach any necessary information and mail it to: HealthKeepers, Inc.

How do I appeal my Anthem claim?

Where can an appeal be filed? Call Member Services at 1-855-817-5785 (TTY: 711) Monday through Friday from 8 a.m. to 8 p.m. This call is free. Fax your written appeal to 1-888-458-1406.

What are claim forms for?

Claim Form legal definition: A claim form is defined as a formal written request to an insurance company, the government, or other entity for compensation you believe you are entitled to under their rules or statutes.

Where do I mail my BCBS FEP claim form?

You can also call 1-800-624-5060 for more information, claim forms and customer service assistance. The claim form provides detailed instructions for submission of the form and should be mailed to: Service Benefit Plan Retail Pharmacy Program, P.O. Box 52057, Phoenix, AZ 85072-2057.

What is a claim action request form?

The document is a Claim Action Request form used to gather information from providers regarding claims for patient services. It includes sections for requestor and claim information, detailing the action requested, and may require additional supporting documentation.

action request form

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Anthem claims action request form 2026

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