Appeals
How to Appeal a Claim Decision — Non-Urgent
If you still disagree with a claim determination after following the steps for filing a claim, you can contact Anthem Blue Cross in writing to formally appeal the claim. If the appeal relates to a claim for payment, your request should include:
  • The patient's name and the identification number from your ID card;
  • The date(s) of medical service(s);
  • The provider's name;
  • The reason you believe the claim should be paid; and
  • Any document or other written information to support your request for claim payment.
Send your appeal to:
Anthem Blue Cross
P.O. Box 4310
Woodland Hills, CA 91365-4310
Your first request to appeal the claim must be submitted to Anthem Blue Cross within 180 days of your receipt of the claim denial.
Appeals Process
Two levels of appeals are provided for each claim. In each appeal step, a qualified individual who was not involved in an earlier denial of your claim will be appointed to decide the appeal. If your appeal is related to clinical matters, the review will be conducted by a health care professional who has appropriate expertise in the specific clinical area and who was not involved in any prior determination. Anthem Blue Cross may consult with, or seek the participation of medical experts as part of the appeal resolution process. If applicable, you must consent to this referral and the sharing of pertinent medical claim information to continue the appeal process. You may request, at no cost, to have access to and copies of all documents, records, and other information relevant to your claim for benefits.
To initiate a second appeal, you must repeat the same steps as those taken for your first claim appeal. Your second-level appeal must be submitted to Anthem Blue Cross within 60 days of your receipt of Anthem Blue Cross' first-level appeal denial.
Appeals Determinations
Pre-Service and Post-Service Claim Appeals
You and your network provider will be provided written notification of Anthem Blue Cross' decision on your appeal as follows:
  • For appeals of pre-service claims, Anthem Blue Cross will conduct the first-level review and notify you of its decision within 15 days of receipt of your request to appeal the denied claim. If your first-level appeal is denied, you may request a second-level appeal review within 60 days of the date on which your first-level appeal was denied. If you request a second-level appeal review, Anthem Blue Cross will also conduct this review and notify you of its decision within 15 days of receipt of your request for a second-level appeal review.
  • For appeals of post-service claims, Anthem Blue Cross will conduct the first-level review and notify you of its decision within 30 days of receipt of your request to appeal the denied claim. If your first-level appeal is denied, you may request a second-level appeal review within 60 days of the date on which your first-level appeal was denied. If you request a second-level appeal review, Anthem Blue Cross will also conduct this review and notify you of its decision within 30 days of receipt of your request for a second-level appeal review.
Please note that Anthem Blue Cross' decision is based only on whether or not benefits are Covered Health Services, as defined by the appropriate medical plan. The determination as to whether the health service is necessary or appropriate is between you and your physician.
Urgent Claim Appeals that Require Immediate Action
Your appeal may require immediate action if a delay in treatment could significantly jeopardize your life, health or the ability to regain maximum function, or cause severe pain. In these urgent situations:
  • Your appeal does not need to be submitted in writing. You or your physician should call Anthem Blue Cross at 800-274-7767 as soon as possible. Anthem Blue Cross will provide you with a written or oral determination within 72 hours following receipt of your request for review of the determination, taking into account the seriousness of your condition.
  • To initiate a second appeal, you must follow the same procedure as outlined under "How to Appeal a Claim Decision — Non-Urgent" or you may call Anthem Blue Cross as described in this section. Your second-level appeal must be submitted to Anthem Blue Cross within 60 days of your receipt of Anthem Blue Cross's first-level appeal decision.