Anthem Overpayment Adjustment Request Form 2012 free printable template

Overpayment Adjustment Request Form For Anthem Blue Cross and Blue Shield members, mail to: Anthem Blue Cross and Blue Shield Attention: Finance Operations Recovery P.O. Box 533 North Haven, CT 064734201

How to fill out Anformm Overpayment Adjustment Request Form

How to fill out Anthem Overpayment Adjustment Request Form

1. Obtain the Anthem Overpayment Adjustment Request Form from the official Anthem website or your provider portal.
2. Fill in the patient’s information, including name, date of birth, and member ID.
3. Specify the service date related to the overpayment in the designated section.
4. Clearly state the reason for the overpayment adjustment request in detail.
5. Attach any supporting documents, such as explanation of benefits (EOB) or billing statements.
6. Review the form for accuracy and completeness before submission.
7. Submit the completed form and any attachments to the appropriate Anthem processing address or via the provider portal.

Who needs Anthem Overpayment Adjustment Request Form?

1. Healthcare providers who have received an overpayment from Anthem for services rendered.
2. Billing departments within medical practices that handle reimbursement requests.
3. Individuals involved in managing claims and adjustments for patient accounts.

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What is Anthem Overpayment Adjustment Request Form?

The Anthem Overpayment Adjustment Request Form is a document used by providers to request an adjustment for overpayments made by Anthem to ensure that reimbursement is corrected according to the actual services provided.

Who is required to file Anthem Overpayment Adjustment Request Form?

Healthcare providers and facilities that have received overpayments from Anthem for services they rendered are required to file the Anthem Overpayment Adjustment Request Form.

How to fill out Anthem Overpayment Adjustment Request Form?

To fill out the Anthem Overpayment Adjustment Request Form, providers need to complete all required fields accurately, including patient information, claim details, and the specific reasons for the requested adjustment.

What is the purpose of Anthem Overpayment Adjustment Request Form?

The purpose of the Anthem Overpayment Adjustment Request Form is to provide a structured process for providers to formally request adjustments on overpayments, ensuring proper reconciliation of billing discrepancies.

What information must be reported on Anthem Overpayment Adjustment Request Form?

The information that must be reported includes the provider's name, National Provider Identifier (NPI), patient information, claim number, date of service, amount of overpayment, and the reason for the adjustment request.