Provider Refund Form

PROVIDER OVERPAYMENT REFUND FORM (Virginia) F

Check here if you are sending a check issued by your practice with this completed form and mail to: Anthem Blue Cross and Blue Shield, VA Recovery, P.O. Box 931766, Cleveland, OH 44193

F

Check here if you are returning a check issued by Anthem with this completed form and mail to: Anthem Blue Cross and Blue Shield, P.O. Box 27401, Richmond, VA 232797401

NOTE: If you prefer to request a retraction (no check enclosed), do not use this form. Instead, please complete a Provider Adjustment Request 151 Form and mail it to: Anthem Blue Cross and Blue Shield, P.O. Box 27401, Richmond, VA 23279-7401.

Refund Information Date: ______________________________ Patient Name _______________________________________ Provider #: _________________________ Member Identification #:_______________________________ Provider Name: ______________________ Patient Account #:___________________________________ Provider Address: _______________________________________________________________________ City: _____________________________ State: _________ Zip:________________________________ Claim #: _______________________________________________________________________________ Date(s) of Service: From: __________________________ To: ___________________________________ Provider Phone Number: ______________________ Refund Check Amount: ________________________ Provider Contact Name: ______________________ Attached Check #: ___________________________

Refund Reason Check one: □ Not our patient NP □ Duplicate payment DU □ Billed in Error BE □ Workers’ Comp WC □ Paid primary but should be secondary to another insurance Carrier CC ƒ Other Carrier Name and Telephone # ______________________________________________ ƒ Member Identification #___________________________ ƒ Policyholder’s employer __________________________ □ Two “Blue” Coverages 2B □ Other (explain) OR __________________________________________________________________________________ __________________________________________________________________________________

Refund Action Taken (For Anthem Use Only) □ □

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Overpayment/Incorrect payment was withdrawn on remittance of: ______________________________ According to our membership records, we are primary and Medicare is secondary. This was verified by: • Coordination of Benefits (COB) Questionnaire sent to employee • Group verified active status of employee Other (explain) __________________________________________________________________________________ __________________________________________________________________________________

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield and its affiliated HMOs, HealthKeepers, Inc., Peninsula Health Care, Inc. and Priority Health Care, Inc., are independent licensees of the Blue Cross and Blue Shield Association. ® Registered marks Blue Cross and Blue Shield Association.

110845 (R12/08)