Anthem Form 151 Adjustment Request Details

The Anthem Form 151 is a 100-page document that contains the provisions of the contract between an insurer and its policyholder. This document includes information on benefits, exclusions, limitations, renewals and amendments to the policy. The first section of this form covers general provisions which includes what will not be covered by the insurance company as well as how to report any changes in your life (such as marriage or divorce). The second section describes what services are included under each coverage type; whether they are hospitalization only or comprehensive. Comprehensive covers everything from emergency care up to surgery while hospitalization only cover you during your stay at a hospital.

This knowledge will help you comprehend better the details of the anthem form 151 before you begin filling it out.

QuestionAnswer
Form NameAnthem Form 151
Form Length1 pages
Fillable?Yes
Fillable fields48
Avg. time to fill out9 min 55 sec
Other namesanthem 151 pdf, anthem 151 fillable, form 151 anthem, form 151

Form Preview Example

Please Mail Form To:

P.O. Box 27401, Richmond, VA 23279-7401

For Federal Employee Program® use:

P.O. Box 105557, Atlanta, GA 30348-5557

Claim Information/Adjustment Request

151 Form

Provider #:

Please complete all sections of this form to assist us when researching your inquiry/adjustment request.

Insured's ID Number:

 

 

 

 

 

 

Claim Filed:

 

 

 

 

 

 

Paper

 

Electronic

 

Date Sent:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(as shown on Patient’s ID card)

 

 

 

 

Claim Type:

 

 

Professional

 

 

Facility

 

 

 

Dental

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient’s Name:

 

 

 

 

 

 

Patient’s Account Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Insurance (if applicable to inquiry)

 

 

 

 

 

 

Claim Number:

 

 

Charge:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please Return To:

 

 

 

 

 

 

Insurance Company:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

Insured’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number:

 

 

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider’s Name and Address:

 

 

 

 

 

Name of Referring Physician:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Certification Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates of Service:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Treatment:

Office

Inpatient Hospital

Outpatient Hospital

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

Other

PLEASE

 

 

 

 

Group Name or Number:

 

 

 

 

 

 

 

 

 

 

 

( DESCRIBE )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason:

 

Additional Information

Adjustment Request:

Attached

 

 

Overpayment

Other: (Explain)

 

 

Underpayment

Claim Information:

Onset Date: ___/___/___

Check Appropriate Box:

Consult Date: ___/___/___

LMP

Accident:

Illness (first symptom)

837 Attachment Control Number:

Briefly Describe Claim Issue and Action Required

(For Internal Use Only)

Reply Date: _______________________________Name: ________________________________________________________

Inquiry Number: ____________________________

(For Internal Use Only)

 

In Virginia: Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. (serving Virginia excluding the city of Fairfax, the town

 

of Vienna and the area east of State Route 123.). Anthem Blue Cross and Blue Shield and its affiliate, HealthKeepers, Inc. are independent licensees of the Blue

 

.

Cross and Blue Shield Association. ®ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

 

The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

 

 

710039 (01/2014)

 

.

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