Coordination of Benefits (COB) Questionnaire Form (For claims prior to 2023)

Please only use this form for information related to claims before 1/1/23. For claims 1/1/23 and after you may contact Anthem at (833) 414-5790 or visit Anthem’s portal at anthem.com/ca or Sydney Health app, go to Profile, then My Account and select “Additional Insurance Policies.

Notify the Plan of other insurance coverage in order to determine the order of benefits/coverage. You can also submit this form by logging in to your Benefits Manager  and selecting 'Forms.'

Accident Questionnaire Form

When you have a claim, if you get into an accident/injury, notify the Plan of the other party's coverage in order to determine the order of benefits/coverage. You can also submit this form by logging in to your Benefits Manager and selecting 'Forms.'

CVS Caremark Rx Claim Form

Get reimbursed for prescription drug claims. This includes submitting prescription receipts for secondary coverage to CVS Caremark.

Medical Claim Form (For claims prior to 2023)

Please only use this form for information related to claims before 1/1/23. For claims 1/1/23 and after you may contact Anthem at (833) 414-5790 or visit Anthem’s portal at anthem.com/ca or Sydney Health app.

Submit medical care claims to the Plan via our secure Benefits Manager portal through the Message Center with the "envelope" icon on the top right. Please be advised that no rights under the Plan, including but not limited to the right to receive any benefit or any right to pursue a Claim or cause of action, are assignable to another party. For more information see the "Authorized Representatives” section of the SPD.

Delta Dental Claim Form

Submit dental care claims if you are treated by a dentist who is not a member of Delta Dental. See instructions on how to submit this form.

Carelon Behavioral Health Claim Form

Submit this form for mental health/substance abuse treatment claims. You may also fill out and submit an online form on the Achieve Solutions website.

Travel Benefits

Complete and submit this form if they incur travel expenses traveling to another state for abortion services.

Health Insurance Claim Form

Health care providers can submit this form for services provided to patients.