Benefit Determinations (Before an Appeal Is Filed)
There are various types of benefit claims. Each benefit claim can be categorized as a post-service, pre-service, urgent, or current claim. Depending on the type of the claim, Anthem Blue Cross must process your claim within different time frames. The processing time frames for each type of claim are explained in this section.
Post-Service Claims
  • Post-Service claims are those claims that are filed for payment of benefits after medical care has been received. If your post-service claim is denied, Anthem Blue Cross will send you a written response in the form of an Explanation of Benefits (EOB) within 30 days of receipt of the claim, provided that all required information was included with the claim. Anthem Blue Cross will notify you within this 30-day period if additional information is needed to process your claim, and may request a one-time extension of no longer than 15 days and pend your claim until all required information is received.
  • If notified that an extension is necessary due to incomplete claim information, you will have 45 days to provide the required information to Anthem Blue Cross. If all of the required information is received within the 45-day time frame and the claim is then denied, Anthem Blue Cross will notify you of the denial within 15 days of receipt of the additional information. If you do not provide the needed information within the 45-day period, your claim will be denied.
  • If your claim is denied, the denial notice -- typically an Explanation of Benefits statement -- will explain the reason(s) for the denial, refer to the Plan provision(s) on which the denial is based, and provide procedures on how to appeal the claim.
Pre-Service Claims
Pre-Service claims are those claims for services that require notification or approval prior to receiving the services. Requests for pre-service claims that are not urgent may be requested by the network provider by calling 800-274-7767 or by submitting the request in writing to:
Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060-0007
If your claim is a pre-service claim and was submitted properly with all the required information, Anthem Blue Cross will send you and your network provider written notice of its claim decision within 15 days of receipt of the claim. If you file a pre-service claim improperly, Anthem Blue Cross will notify you and the network provider that the claim was improperly filed within five days of receiving the pre-service claim and will give you information on how to correct it. If additional information is needed to process the pre-service claim, Anthem Blue Cross will notify you within 15 days of receipt of the claim that additional information is needed, and may request a one-time extension of no longer than 15 days and pend your claim until all required information is received.
If notification of an extension is necessary due to incomplete claim information, you will have 45 days to provide the required information to Anthem Blue Cross. If all of the required information is received within the 45-day time frame, Anthem Blue Cross will notify you of its determination within 15 days of receipt of the additional information. If you don't provide the required information within the 45-day period, your claim will be denied.
If your claim is denied, the denial notice will explain the reason(s) for the denial, refer to the Plan provision(s) on which the denial is based, and provide procedures on how to appeal the claim.
Urgent Claims that Require Immediate Action
Urgent care claims are those claims (1) that require notification or approval prior to receiving medical care, and (2) where a delay in treatment could jeopardize your life, health, or the ability to regain maximum function or, in the opinion of a physician with knowledge of your medical condition, could cause severe pain. In these situations, you or your network provider may submit your request in writing to Anthem Blue Cross or call Anthem Blue Cross at 800-274-7767. After Anthem Blue Cross receives the request, you will receive a response as follows:
  • You and your network provider will receive notice of the benefit determination in writing or by telephone within 72 hours of Anthem Blue Cross' receipt of all necessary information, taking into account the seriousness of your condition. Notice of denial may be oral with a written confirmation to follow within three days.
  • If you file an urgent care claim improperly, Anthem Blue Cross will notify you or your network provider within 24 hours of receiving the urgent claim that the claim was improperly filed and will give you information on how to correct it. If additional information is needed to process the claim, Anthem Blue Cross will notify you or your network provider of the information needed within 24 hours of receiving the claim. You will have 48 hours to provide the requested information.
You and your network provider will be notified of Anthem Blue Cross' determination no later than 48 hours after:
  • Anthem Blue Cross' receipt of the requested information; or
  • The end of the 48-hour period within which you were to provide the additional information, if the information is not received within that timeframe.
If your claim is denied, the notice of the denial will explain the reason(s) for the denial, refer to the Plan provision(s) on which the denial is based, and provide procedures on how to appeal the claim.
Concurrent Care Claims
If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and you or your network provider requests to extend the treatment as an urgent care claim, Anthem Blue Cross will make a determination on your request within 24 hours of receiving your request, provided your request is made at least 24 hours prior to the end of the approved treatment. If your request for extended treatment is not made at least 24 hours prior to the end of the approved treatment, the request will be treated as an urgent care claim and handled according to the described time frames.
If an ongoing course of treatment was previously approved for a specific period of time or number of treatments, and you or your network provider requests to extend treatment in a non-urgent circumstance, your request will be considered a new claim and decided according to post-service or pre-service time frames, whichever applies.
Concurrent claims that are considered urgent may be submitted by calling Anthem Blue Cross at 800-274-7767. Non-urgent claims may also be submitted in writing to:
Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060-0007