Download Anthem Blue Cross Blue Shield Insurance Claim Form ... 2026

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The document is a Member Claim Form for the Healthy Families Program, designed for patients to report covered health services not billed directly by providers. It includes sections for patient and subscriber information, medical details about services rendered, and instructions on how to complete the form accurately. The form emphasizes the need for itemized bills and provides guidance on submitting claims to Anthem Blue Cross.

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Send anthem out of network claim form via email, link, or fax. You can also download it, export it or print it out.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Patient Information' section. Enter the patient's name, birthdate, and sex. Ensure you include the subscriber's information as found on the Anthem Blue Cross card.
In the 'Medical Information' section, report any covered health services not already billed to Anthem. Attach itemized bills or photocopies as required.
Indicate if the medical expense was due to an accident or job-related injury. Provide details such as the date of service and provider of service.
Complete the certification statement at the bottom by signing and dating it, confirming that all information is accurate.

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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.

How long do I have to file a claim with Anthem Blue Cross?

If the healthcare providers information is entered anywhere incorrectly in Anthems system, they will process the claim as out-of-network. If you dont have out-of-network coverage, it will be denied.

Is Anthem the same as Blue Cross Blue Shield?

Anthem follows the standard of: 90 days for participating providers and facilities. 180 days for nonparticipating providers and facilities (For dates of service prior to January 1, 2019, 12 months for nonparticipating providers).

Why is Anthem denying my claims?

Most Blue Cross NC members can submit medical claims online through Blue Connect. Just enter some information, upload a copy of your receipt, and hit submit! If you prefer to submit a paper claim form, you can download the form you need, fill it out, and send it to the mailing address or fax number provided.

anthem submit claim online

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