Anthem Form 151 PDF Details

The Anthem 151 form serves as a crucial nexus between healthcare providers and insurance companies, specifically designed to streamline the process of claims information and adjustment requests. By compiling essential details like the provider's data, the insured's identification number, the nature of the claim (whether it's related to professional services, facilities, or dental work), and the type of claim filing (paper or electronic), this form embodies an organized effort to address and rectify billing and payment discrepancies. It ensures a standardized communication channel for inquiries related to overpayments, underpayments, or other insurance matters that may arise after the submission of a healthcare claim. With sections prompting for detailed descriptions of the claim issue and the action required, the Anthem 151 form acts as a comprehensive tool for both resolving disputes and facilitating a smoother healthcare billing experience. Directed to specific postal addresses based on the Federal Employee Program® or other needs, this document reflects a tailored approach to claims management. As part of the Anthem Blue Cross and Blue Shield’s protocol, which operates under specific trade names in various regions while integrating with the broader network of Blue Cross and Blue Shield Association affiliates, this form emphasizes the interconnected nature of modern healthcare administration and the paramount importance of clear, accurate, and efficient claims processing.

QuestionAnswer
Form NameAnthem Form 151
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesanthem 151, 151 bcbs, anthem 151 fillable, anthem form 151 adjustment request

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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Step 1: Choose the button "Get Form Here" on the webpage and select it.

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