Anthem Claim Form - Flu Shot Only Page 2
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1
2How to File Your Claim
Required information
Be sure to ask your provider of care if he/she bills a statement to
Anthem Blue Cross and Blue Shield. Please submit statements only if
Itemized Bills: Summarizing the services may help us better understand
the provider does not bill us directly. To receive benefits for RX, or for
the attachments if they are not clear. The attached itemized bills must
services by a provider who does not bill us directly, complete the claim
include the provider name, patient’s name, date of service, detailed
form, attach itemized bills, proof of payment (if applicable) and mail the
description of service, and amount charged for that service. These must
white copy to Anthem Blue Cross and Blue Shield, P.O. Box 5747, Denver,
be valid documents from the provider.
Colorado 80217-5747.
Helpful hints
Keep a duplicate copy of your itemized bills and proof of payment as
they will not be returned to you. This claim may be returned to you if all
If you have questions or need assistance, contact Anthem Blue Cross
£
required information is not present.
and Blue Shield Customer Service.
To reduce the possibility of small billings getting lost or separated,
£
Claim filing instructions
it would be helpful if you attach these to an 8 1/2x11 piece of paper.
(Corresponds to numbered items on claim form)
We encourage you to file claims within 90 days of the service date.
£
A separate claim form for each family member and each provider of care
Please refer to your Benefit Certificate for specific timely filing
must be submitted.
limitations.
File only if the provider has not.
£
Item number
important: if the services for this claim were provided by a
1–8 Please complete all blocks. All fields required.
participating physician or hospital, the benefit payment will go
9-9c Appropriate responses to these questions will ensure expedient
to the provider.
and proper handling of your claim.
A complete description of your benefits, as well as limitations and
10 Indicate the name of the flu clinic that rendered the service.
exclusions applicable thereto, is available in the Benefit certificate.
Final interpretation of any and all provisions of the program is
11 The date the flu shot was administered.
governed by the Benefit certificate.
12 Indicate the total charge for the flu shot.
13 Name and telephone number; whoever can help us if additional
information is required.
14 Your signature attests to the accuracy and completeness of all
information on the claim and the attachments and authorizes the
release of your medical records by the provider to our office if
necessary.
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