If you disagree with the outcome of a claim, you may begin the Anthem Blue Cross and Blue Shield (Anthem) provider claims dispute process. The simplest way to define a claim dispute is when the claim is finalized, but you disagree with the outcome.

 

For more information on the claim dispute process, please see the table below, or reference the attached PDF titled "Anthem provider claims dispute process."

Appeal/ dispute type

When do I use it?

How do I request?

Timeframe

Required documentation

Step one: Claim payment reconsideration — Step one in the claim payment dispute process

Initial request for an investigation into the outcome of the claim in question. Most issues are resolved at the claim payment reconsideration step. Please note that we cannot initiate this review if there are no finalized claims on file.

Claim payment reconsiderations can be submitted via phone by calling the number on the back of the member ID card, the Availity* website, or in writing to:

Anthem Blue Cross and Blue Shield

Attention: Provider Disputes

P.O. Box 105449

Atlanta, GA 30328-5449

You have 12 months from the issue date of the Explanation of Payment (EOP) to submit a claim payment reconsideration, unless otherwise specified in your contract.

 

The following information is required when submitting claim payment reconsideration or claim payment appeal:

· Provider or facility name, address, phone number, email, and either NPI or TIN

· The member’s name and Anthem or Medicaid ID number

· The Anthem claim number and the date of service

· All supporting statements and documentation

 

Step two: Claim payment appeal — Step two in the claim payment dispute process

If you disagree with the outcome of Step one: Claim payment reconsideration, you may request an additional review as a claim payment appeal.

 

 

A claim payment appeal can be submitted through Availity, or in writing to:

Anthem Blue Cross and Blue Shield

Attention: Provider Disputes

P.O. Box 105449

Atlanta, GA 30328-5449

 

A claim payment reconsideration must be submitted prior to submitting a claim payment appeal.

A claim payment appeal must be submitted within 30 days from the date of the determination of the claims payment reconsideration, unless otherwise specified in your contract.

 

Clinical appeal

If you disagree with a clinical decision, you may request a clinical appeal review. A clinical appeal is a request to change decisions based on whether services or supplies are medically necessary or experimental/ investigative.

 

 

Clinical appeals can be made verbally, by using Interactive Care Reviewer for appeals, or in writing to:

Anthem Blue Cross and Blue Shield

Attention: Grievances and Appeals

P.O. Box 105568

Atlanta GA 30348-5568

 

Providers and facilities have 180 calendar days to file a clinical appeal from the date they receive notice of Anthem's initial decision, unless otherwise specified in your contract.

The following information is required when submitting a clinical appeal:

· Provider or facility name, address, phone number, email, and either NPI or TIN

· The member’s name and Anthem ID number

· The Anthem claim, authorization or reference number and the date of service

· Specific reason(s) for disagreement with decision

· All supporting statements and documentation

· A signed Designation of Representation (DOR) is needed if the provider is appealing on behalf of the member. No DOR is required when the provider is appealing on their own behalf.



* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield.

GABCBS-CM-006990-22



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