Anthem (Elevance Health): insurance claim denied
Read the EOB and denial letter, file the internal appeal at the address on the letter, then ask for external review or complain to the state or Medicare.
What does this mean?
Grade A (high: almost everything comes from official pages read directly). 100% of 14 sources are the organization's own pages or government sites.
Collect
- denial letter or EOB
- member ID card
- medical records
- provider letter of medical necessity
Steps
Log in and download the EOB for the claim. Note the denial reason code.
Ask member services or chat for the reason and the plan document section it relies on.
File the internal appeal at the address and within the deadline printed on the denial letter. Medicare plan members use the Medicare appeals address or fax.
MailAppeals and grievances for Anthem Medicare plans Appeals and Grievances, Mailstop OH0102-B325, 4361 Irwin Simpson Rd, Mason, OH 45040After the final internal denial, request external review through the state insurance department (fully insured plans) or the plan's external review process. For employer self-funded plans, contact the Department of Labor.
More contacts for this issue
Facts you can cite
- Process
Anthem says that if a Medicare member has exhausted the options with Anthem, the member can submit feedback directly to Medicare through the Medicare complaint form.
Source: anthem.com, verified 2026-10-12
Rules in force
- ACA internal appeals and external review for health coverage45 CFR 147.136 (with 29 CFR 2560.503-1 for group health plans)
After a health plan denies a claim, the patient has 180 days to file an internal appeal. The plan must decide within 30 days (care not yet received), 60 days (care already received) or 72 hours (urgent care). After a final denial, the patient can ask for an independent external review within 4 months; the plan must accept the reviewer's decision.
Source: law.cornell.edu, verified 2026-10-12
10 citable points
- Deadline
"You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied."
Source: healthcare.gov, verified 2026-10-12
- Deadline
The internal appeal must be completed within 30 days for a service not yet received and within 60 days for a service already received.
Source: healthcare.gov, verified 2026-10-12
- Deadline
For urgent care claims, a group health plan must decide an appeal "not later than 72 hours after receipt of the claimant's request for review".
Source: law.cornell.edu, verified 2026-10-12
- Process
In urgent situations, "You may file an internal appeal and an external review request at the same time."
Source: healthcare.gov, verified 2026-10-12
- Policy
Plans must continue coverage pending the outcome of an appeal, and may not reduce or end benefits for an ongoing course of treatment without advance notice and an opportunity for advance review.
Source: law.cornell.edu, verified 2026-10-12
- Deadline
An external review must be requested within "4 months after the date you receive a notice or final determination" from the insurer. A standard decision is due no later than 45 days after the request is received; an expedited decision no later than 72 hours.
Source: healthcare.gov, verified 2026-10-12
- Policy
The insurer is required by law to accept the external reviewer's decision. The HHS-administered process is free; a state or insurer-contracted process may charge, but not more than $25 per review.
Source: healthcare.gov, verified 2026-10-12
- Policy
If the plan fails to strictly follow the internal claims and appeals requirements, the claimant "is deemed to have exhausted the internal claims and appeals process", subject to a de minimis exception.
Source: law.cornell.edu, verified 2026-10-12
- Limit
These internal appeal and external review requirements generally do not apply to grandfathered plans.
Source: law.cornell.edu, verified 2026-10-12
- Contact
For plans that use the HHS-administered external review process, requests can be filed online with MAXIMUS Federal Services, by calling 1-888-866-6205 for a form, or by email to ferp@maximus.com. For a state process, the contact is in the final denial notice or Explanation of Benefits.
Source: healthcare.gov, verified 2026-10-12
- Deadline
- ERISA claims procedure timelines for employer benefit plans29 CFR 2560.503-1
Employer-sponsored benefit plans covered by ERISA must decide claims and appeals within set deadlines. Group health plans: 72 hours for urgent care, 15 days for pre-service and 30 days for post-service claims; disability plans: 45 days; other plans: 90 days. Group health and disability claimants get at least 180 days to appeal. If the plan does not follow the procedures, the claimant may sue.
Source: law.cornell.edu, verified 2026-10-12
7 citable points
- Deadline
Group health plan initial decisions: urgent care claims "not later than 72 hours after receipt of the claim by the plan"; pre-service claims within 15 days, with one extension of up to 15 days; post-service claims "not later than 30 days after receipt of the claim", with one extension of up to 15 days.
Source: law.cornell.edu, verified 2026-10-12
- Deadline
Disability claims: notice of decision "not later than 45 days after receipt of the claim by the plan", with an extension of up to 30 days and a second extension of up to 30 days. Other plans (not group health or disability): not later than 90 days, with one extension of up to 90 days.
Source: law.cornell.edu, verified 2026-10-12
- Deadline
Time to appeal a denial: group health plan and disability claimants must have at least 180 days after receiving the adverse benefit determination. Claimants under other plans must have "at least 60 days following receipt of a notification" of the adverse determination.
Source: law.cornell.edu, verified 2026-10-12
- Deadline
Group health plan appeal decisions (one-level appeal): urgent care within 72 hours, pre-service within 30 days, post-service within 60 days after the plan receives the appeal. With two appeal levels, each level has 15 days (pre-service) or 30 days (post-service).
Source: law.cornell.edu, verified 2026-10-12
- Deadline
Appeal decisions for other plans are due not later than 60 days after the request for review (up to 60 more days in special circumstances); for disability plans the period is 45 days.
Source: law.cornell.edu, verified 2026-10-12
- Policy
On appeal, the plan must provide, "upon request and free of charge, reasonable access to, and copies of, all documents" relevant to the claim.
Source: law.cornell.edu, verified 2026-10-12
- Policy
If the plan fails to establish or follow these claims procedures, "a claimant shall be deemed to have exhausted the administrative remedies available under the plan" and may bring a civil action under ERISA section 502(a).
Source: law.cornell.edu, verified 2026-10-12
- Deadline
If that fails, escalate
Go up one step at a time. Keep the reference numbers and dates from each contact.
Customer service
Use the number on the back of the member ID card, or live chat.
Written complaint
MailAppeals and grievances for Anthem Medicare plans Appeals and Grievances, Mailstop OH0102-B325, 4361 Irwin Simpson Rd, Mason, OH 45040Internal appeal or grievance. Medicare plans use this address; other plans use the address on the denial letter.
State agency
Your state’s insurance department. Find it in the list of state agencies (also as JSON:
states/<code>.json, for example states/ny.json).External review for fully insured plans; complaint to the state.
Federal regulator
Employer self-funded (ERISA) plans.
Federal regulator
Surprise bills under the No Surprises Act.
Watch out
- Member phone numbers, appeal forms and plan documents depend on the state and plan and are mostly behind member login.
- Anthem publishes no public appeal address for employer or individual plans; use the address on the denial letter or EOB.
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