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PW_AD089370

Anthem provides you with the following forms to help you take care of our members.

Claims and Billing
Title	Form No.	Rev Date	Format
ERA/EFT Form (Hoosier Healthwise)			PDF
ERA Enrollment Form (Healthy Indiana Plan)		01/01/09	PDF
CMS 1450 (UB-04) Claim Form	CMS1450		PDF
CMS 1500 Claim Form	CMS1500	08/05	PDF
Claim Follow Up Form	INW1226	03/13	Word

Grievances and Disputes
Title	Form No.	Rev Date	Format
Provider Dispute Resolution Request	INW1245	03/13	Word
Provider Grievance Form	INW1210	03/13	Word
Member Grievance Form	INW1217	03/13	Word
Fraud Referral Form	INW1221	05/13	Word

Changes and Referrals
Title	Form No.	Rev Date	Format
Care Management Referral Form	INW1211	03/13	Word
Provider Change Form	INW1227	02/13	Word
Provider Request for Member Deletion From PMP Assignment	INW1220	03/13	Word
Record of Referral to Specialty Care	INW1218	03/13	Word
Request for Professional Provider Practice Information Form	INW2212	03/13	Word

Clinical and Preventive Care Tools (Chart Forms and Resources)
Title	Form No.	Rev Date	Format
17-P Reimbursement Request		03/13	Word
Pregnancy Notification Report This form should only be used when the state's Notification of Pregnancy online process will not accept your patient's information.		03/13	PDF
Pregnancy Assess - 2nd Trimester	INW1215	03/13	Word
Pregnancy Assess - 3nd Trimester	INW1214	03/13	Word
Pre-Birth Selection Form	INW1207	03/13	Word
Newborn Enrollment Notification Report	INW0234	02/11	Word
Postpartum Checkup	INW1213	03/13	Word
Preventive Care Forms		10/08	HTML

Other Forms
Title	Form No.	Rev Date	Format
Full Panel and Hold Panel Add Request Form	INW2078	04/13	Word
Transitions Program Appointment Authorization Worksheet		04/13	Word
Asthma Progress Chart Note	0013508	12/06	PDF
Outreach Request	INW1223	04/13	PDF
Behavioral Health Treatment Data Sharing Form	INW3055	04/13	Word
HHW/HIP Outpatient Treatment Request (OTR)		08/11	PDF
POM Acknowledge Form	INW1224	04/13	Word
Request for Authorization for Synagis		04/13	PDF
Interpreter Attendance Verification Form	INW1116	04/09	Word

Last Update: 4/2/2013 Version 7

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©2005-2013 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. 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. Use of the Anthem Web sites constitutes your agreement with our Terms of Use