Healthy Blue Provider Complaint Form

1. Contact Us Information

• Contact Us Information

complaint_form@anthem.com

Email a Provider associate compliant form.

Provider Information

All fields are required unless noted as optional.

*Provider Name or Provider Group

*Provider Type

Select One Hospital PCP/Specialist Behavioral Health ABA OON

*Provider Office Contact Name

*Provider Office Contact Email

*Provider Office Contact Phone

*Parish

Select One Acadia Allen Ascension Assumption Avoyelles Beauregard Bienville Bossier Caddo Calcasieu Caldwell Cameron Carroll Cassie Catahoula Claiborne Concordia DeSoto East Baton Rouge East Carroll East Feliciana Evangeline Franklin Grant Iberia Iberville Jackson Jefferson LaSalle Lafayette Lafourche Lincoln Livingston Madison Morehouse Natchitoches Orleans Ouachita Plaquemines Pointe Coupee Rapides Red River Richland Sabine St. Bernard St. Charles St. Helena St. James St. John the Baptist St. Landry St. Martin St. Mary St. Tammany Tangipahoa Tensas Terrebonne Union Vermilion Vernon Washington Webster West Baton Rouge West Carroll Out of state

*Provider Tax ID (TIN)

*Provider NPI

*Initial Primary Complaint Category

Select One Demographic Data Update Timeliness Disagree with Healthy Blue Payment Policy Disagree with result of previously filed claim appeal Disagree with other Healthy Blue policy or procedure Interaction with Healthy Blue Staff Other

*Initial Detail Explanation

*If "Other" please specify:

*Complaint Reason Code

Select One LDH Complaints Incorrect Claim Payment Reimbursement Rates Prior Authorization Provider Enrollment/Provider Credentialing/Re-Credentialing Lack of Information/Response Recoupment Third Party Liability Lower Level of Care Other

*If "Other" please specify:

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