Anthem Claim Denied: A Complete Guide to Appealing Your Denial

Anthem, Inc. — now operating under the brand name Elevance Health — is one of the largest health insurers in the United States, covering more than 40 million people through its Blue Cross Blue Shield affiliates in 14 states, as well as commercial plans, Medicare Advantage, and Medicaid programs. If Anthem has denied your health insurance claim, you have the legal right to appeal.

This guide covers Anthem's appeal process for commercial, Medicare Advantage, and Medicaid members.

Anthem's State Affiliates

Anthem operates BCBS plans in 14 states under various brand names:

• Anthem Blue Cross (California)
• Anthem Blue Cross and Blue Shield (Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, Ohio, Virginia, Wisconsin)
• Empire BlueCross (New York)

Anthem also operates non-BCBS commercial plans, Medicare Advantage plans under the Anthem brand, and Medicaid managed care plans. Your plan documents and member ID card identify which Anthem entity covers you.

Why Anthem Denies Claims

Anthem denies claims for many reasons, including:

• Medical necessity: The service did not meet Anthem's clinical criteria, which may be reviewed by AIM Specialty Health or eviCore for specialty services
• Prior Authorization Denied: How to Appeal" class="auto-link">Prior authorization not obtained: Prior approval was required but not obtained before care
• Out-of-network provider: Care was received from a non-network provider without approval
• Timely filing: Anthem received the claim after the filing deadline
• Experimental or investigational: The treatment was classified as unproven under Anthem's clinical policy
• Benefit limits exceeded: For example, physical therapy or mental health visit limits
• Coding or billing errors: Incorrect CPT, ICD-10, or provider information

Step 1: Get Your Full Denial Documentation

Call Anthem Member Services (number on your ID card) or log into the Sydney Health app or anthem.com to access your EOB)" class="auto-link">Explanation of Benefits (EOB) and denial letter.

Request the complete adverse benefit determination letter, which must include:

• The specific reason for denial
• The clinical criteria or plan provision applied
• The reviewer's name and credentials
• Your appeal rights and deadline

Step 2: Check for Billing Errors

Work with your provider's billing department to confirm:

• CPT and ICD-10 codes are correct
• The provider is in-network for your specific Anthem plan
• The claim was submitted within the timely filing window
• The member ID and group number are accurate

Many denials are resolved through corrected claims without formal appeals.

Step 3: Peer-to-Peer Review

For medical necessity or prior authorization denials, your physician should call Anthem to request a peer-to-peer review with an Anthem or AIM Specialty Health Medical Director. AIM Specialty Health manages authorization for many specialty procedures under Anthem plans.

If AIM Specialty Health managed the authorization, your doctor can call AIM directly at 1-800-252-2021 to request peer-to-peer review.

Step 4: File a First-Level Internal Appeal

ACA-compliant plans:

• Urgent (expedited): 72 hours
• Pre-service: 30 days
• Post-service: 60 days
• Filing deadline: typically 180 days from denial

ERISA employer plans:

• Pre-service: 15 days
• Post-service: 60 days

You can submit appeals through:

• Sydney Health app: Anthem's mobile app for members
• Anthem member portal at anthem.com
• Mail: Anthem Appeals, address on your denial letter (varies by state)
• Fax: Number listed on the denial letter

Include in your appeal:

• Written appeal letter citing the denial date and claim number
• Physician letter of medical necessity addressing Anthem's specific criteria
• Relevant medical records, office notes, labs, and imaging
• Published clinical guidelines from specialty organizations
• Prior authorization approvals, if applicable

Step 5: Second-Level Internal Appeal

If Anthem denies your first-level appeal, most plans allow a second internal review by a physician reviewer with the appropriate specialty. Confirm your plan's appeal levels by reviewing your Summary Plan Description or calling Anthem member services.

Step 6: External Independent Review

After exhausting internal appeals, request an external independent review from an accredited IROs) Explained" class="auto-link">Independent Review Organization (IRO). The external reviewer's decision is binding on Anthem.

• File within 4 months of the final internal denial
• Standard review: 45 days
• Expedited review: 72 hours

Step 7: File a Complaint with State Regulators

Anthem is subject to state insurance regulation in each state where it operates. If Anthem violated procedural requirements, file a complaint with your state insurance department.

Key state insurance departments for Anthem:

• California: California Department of Insurance (cdinsurance.ca.gov) or DMHC (dmhc.ca.gov) for HMO plans
• New York (Empire): New York Department of Financial Services (dfs.ny.gov)
• Georgia: Georgia Office of Insurance and Safety Fire Commissioner (oci.ga.gov)
• Indiana: Indiana Department of Insurance (in.gov/idoi)
• Virginia: Bureau of Insurance (scc.virginia.gov/pages/bureauofinsurance)

For all other states, find your regulator at naic.org.

For ERISA self-funded employer plans, contact the Department of Labor's EBSA at 1-866-444-3272.

Fight Back With ClaimBack

Anthem's appeal process involves multiple levels and, for specialty services, coordination with third-party reviewers like AIM Specialty Health. ClaimBack helps you build a well-documented appeal that addresses the right criteria at every stage.

Start your appeal with ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs. External Insurance Appeals