1. Anthem Blue Cross and Blue Shield “Serving Hoosier Healthwise” State Sponsored Business Managed Care Forms October 2008 Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc. Independent licensee 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.

2. 2 Anthem Provider Forms - Overview Forms and Tools Library Anthem provides you with the following forms, tools, and additional resources to help you take care of our members. The below list is does not include all forms. You can find a more complete list by going to Anthem’s website www.anthem.comwww.anthem.com Claims and Billing EFT/ERA Claims Follow up Claims Resubmission Grievances and Disputes Provider Dispute Resolution (PDR) Provider/Member Grievance Billing Dispute External Review Process Fraud Referral Form Changes and Referrals Case Management Referral Provider Request for Member Deletion Request for Professional Provider Information Pregnancy and Childbirth Pregnancy Notification Newborn Enrollment Notification Report Pre-birth Selection Other Forms Mental Health Consent Form Outreach Request Form Full Panel Add Request Form

3. 3 Provider Online Resources

4. 4 Forms and Tools Library

5. 5 Claims and Billing Forms EFT/ERA Form EFT: Electronic Claims Transfer Claims payments deposited directly into a bank account. Enroll by calling EDI Services at 1-800-470-9630 ERA: Electronic Remittance Advice Received through the SPC: MAILBOX. Implementation guides are available at no charge at www.wpc-edi.com/hipaa. Enrollment is required. Providers can enroll by calling EDI Services at 1-800-470-9630. Electronic data transfers and claims are HIPAA- compliant and meet federal requirements for EDI transactions, code sets, member confidentiality, and privacy. Completed EFT/ERA claims can be faxed or mailed to: Attention: Maryjo Johnson, PCDA 5151-A Camino Ruiz, Mailstop CACD01-042C Camarillo, CA 93012 Phone: 805-384-7406 Fax:866-652-1236 EFT/ERA Enrollment Form

6. 6 Claims and Billing Forms (continued) Claim Follow- Up/Resubmission Forms Follow-up to determine claim status if there has been no response from Anthem to a submitted claim after 30 business days from the date the claim was submitted: Check Anthem for disposition of the claim, Check the Interactive Voice Response (IVR) for disposition of the claim, or Contact the Customer Call Center (CCC) Provide a copy of the original claim submission and all supporting documentation (such as records and reports) that you deem pertinent or that has been requested by Anthem. Anthem Blue Cross Blue Shield State Sponsored Business Claim Follow up Form

7. 7 Claim Follow-Up/Resubmission Forms (cont’d) Anthem Blue Cross Blue Shield State Sponsored Business Claim Resubmission Form Claims and Billing Forms (continued)

8. 8 Grievances and Disputes

9. 9 Provider Dispute Resolution Form Complete Provider Dispute Resolution Request with all points of contention itemized and explained Include: A copy of the original/corrected CMS- 1500 or CMS-1450 claim form Any and all supporting documentation (such as records, reports) that you deem pertinent or that we have requested Anthem sends acknowledgement of receipt to all provider claim disputes within five business days from the date Anthem receives of the dispute. Determination is made in 45 business days from Anthem’s receipt of dispute. Anthem Blue Cross Blue Shield State Sponsored Business Provider Dispute Form

10. 10 Grievances and Disputes (continued) Provider Grievance Form Providers may file a grievance in writing or fax. May be filed up to 60 calendar days of the date the provider became aware of the issue. Anthem will send a written acknowledgement to the provider within 5 calendar days of receiving a provider grievance. Anthem sends a written resolution letter to the provider within 30 calendar days of the receipt of the grievance. Anthem Blue Cross Blue Shield State Sponsored Business Physician/Provider Grievance Form

11. 11 Grievances and Disputes (continued) Billing Dispute External Review Process Form After exhausting internal physician appeal process for a medical necessity or experimental / investigational adverse determination Submit a written request for an external review of the internal physician appeal within 60 calendar days from the date of the notice of our internal appeals decision Any decision issued pursuant to the external review process is binding upon the physician Anthem Blue Cross Blue Shield State Sponsored Business Billing Dispute External Review Process

12. 12 Grievances and Disputes (continued) Fraud Referral Form Any type of intentional deception or misrepresentation made with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. Anthem Blue Cross Blue Shield State Sponsored Business Fraud Referral Form

13. 13 Changes and Referrals

14. 14 Changes and Referrals Case Management Referral Form Anthem Blue Cross Blue Shield State Sponsored Business Case Management Referral Form This person submitting the referral for care Management or continuity of care should complete this form. When complete please fax to care management at 1-866-406- 2808. Thank you for your referral!

15. 15 Changes and Referrals (continued) Provider Request for Member Deletion from PMP Assignment Form A PMP can request a member reassignment to another PMP by completing and submitting the Provider Request for Member Deletion from PMP Assignment form Provider Request for Member deletion from Primary Medical Provider (PMP) Assignment Anthem Blue Cross Blue Shield State Sponsored Business

16. 16 Changes and Referrals (continued) Request for Professional Provider Practice Information Anthem Blue Cross Blue Shield State Sponsored Business Request for Professional Provider Practice Information

17. 17 Pregnancy and Childbirth

18. 18 Pregnancy and Childbirth Pregnancy Notification Report State Sponsored Business Anthem Blue Cross Blue Shield Pregnancy Notification Report

19. 19 Pregnancy and Childbirth (continued) Newborn Enrollment Form Newborn Enrollment Notification Report Anthem Blue Cross Blue Shield State Sponsored Business

20. 20 Pregnancy and Childbirth (continued) Pre-birth Selection Form for Hoosier Healthwise Members Anthem Blue Cross Blue Shield State Sponsored Business Prebirth Selection Form for Hoosier Healthwise Members

21. 21 Other Forms

22. 22 Other Forms Mental Health Consent Form

23. 23 Other Forms (continued) Outreach Request State Sponsored Business Anthem Blue Cross Blue Shield Outreach Request Form

24. 24 Other Forms (continued) Full Panel Add Request Form Anthem Blue Cross Blue Shield State Sponsored Business Full Panel Add Request Form