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Anthem Blue Cross Member Claim Form (114027NYMENABC), page 1
Moderate · 53/100Form Complexity Index

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What this form asks for

The AI fills all of it, from your answers or your documents.

This is a claim form for members of Anthem Blue Cross to submit requests for benefits when a healthcare provider does not file the claim on their behalf. It requires detailed information about the member, patient, diagnosis, and any other insurance coverage, and must be submitted with an itemized bill. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
Fillable fields47
Pages1
Sections7
Questions that depend on earlier answers18
Form Complexity IndexModerate, 53/100

The AI checks your answers before you download

14 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Required Member Identification Number

This check ensures the 'Member identification no.' field in Section 1 is not empty. This number is the primary identifier for the member's policy and is essential for accessing their coverage and benefits information. A missing Member ID will result in an immediate rejection of the claim, as it cannot be associated with any policy in the system.

Standard Date Format (MMDDYYYY)

This validation verifies that all date fields on the form, such as 'Patient Date of Birth' and 'Date of accident', strictly follow the MMDDYYYY format. Enforcing a standard format is crucial for data consistency and prevents system errors during date-based calculations like age verification or timely filing checks. Submissions with incorrectly formatted dates will fail processing and must be corrected.

Logical Patient Date of Birth

This check validates that the 'Patient Date of Birth' in Section 2 is a real, historical date and not a date in the future. This is a fundamental check to prevent obvious data entry errors and confirm the patient's age for eligibility purposes. A claim with an invalid or future date of birth cannot be processed and will be flagged for immediate correction.

Exclusive Relationship to Subscriber Selection

This validation ensures that one and only one checkbox ('Self', 'Spouse', 'Son', 'Daughter') is selected in the 'Relationship to subscriber' part of Section 2. A patient can only have one primary relationship to the subscriber for a given policy. If zero or more than one option is selected, the claim will be rejected due to ambiguity.

Patient and Member Name Consistency for 'Self' Relationship

This check verifies that if 'Self' is selected as the 'Relationship to subscriber', the patient's first and last names in Section 2 match the member's first and last names in Section 1. This cross-field validation confirms that the member is the patient, preventing processing errors due to mismatched identities. A discrepancy would trigger a review or rejection pending clarification.

Logical Accident Date

This validation ensures that if a 'Date of accident' is provided in Section 3, it is a valid date that occurs on or before the signature date. This check prevents claims for future events, which are logically impossible. An accident date that is in the future or after the form was signed would invalidate the claim and require correction.

And 8 more checks
  • Conditional Requirement for Work-Related Details
  • Conditional Requirement for Other Insurance Details
  • Conditional Requirement for Medicare Details
  • Medicare Part Effective Date Validation
  • Required Signature and Date
  • Logical Signature Date Chronology
  • Valid State Abbreviation Format
  • Valid 5-Digit ZIP Code Format

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How to Fill Out 114027NYMENABC Online for Free in 2026

What the AI walks you through.

  1. Navigate to Instafill.ai and upload or select the Anthem Blue Cross Member Claim Form.
  2. Provide your personal details for Section 1 (Member Information) and Section 2 (Patient Information), including names, member ID, and relationship to the subscriber.
  3. Complete Section 3 by describing the illness or injury and providing the date if it was an accident.
  4. Answer the questions in Sections 4, 5, and 6 regarding work-related incidents, other health insurance, and Medicare coverage.
  5. Carefully review all the information auto-filled by the AI for accuracy and completeness.
  6. Digitally sign and date the form in Section 7 to authorize the release of information and certify the claim's accuracy.
  7. Download the completed form, attach copies of your itemized medical bills, and submit it to the Anthem Blue Cross address provided.

Common Mistakes in Completing 114027NYMENABC

The ones the AI is built to catch.

Missing or Incorrect Member Identification Number
This is the most critical piece of information for processing a claim, but it's often long and easily mistyped. People may also confuse it with the Group Number. Without the correct Member ID, the system cannot locate the policy, leading to an immediate rejection or significant processing delays. Always double-check this number against the insurance card before submitting. AI-powered tools like Instafill.ai can securely store and accurately auto-fill this number to prevent transcription errors.
Failing to Attach a Proper Itemized Bill
Many people mistakenly submit a credit card receipt or a simple 'balance due' statement, which are not sufficient. The form instructions explicitly state that a detailed, itemized bill is required, including the provider's tax ID, diagnosis codes, and procedure codes. Submitting the wrong document will cause the claim to be rejected, as the processor has no way to verify the services rendered. Always request the 'itemized bill' from your provider for insurance submission purposes.
Missing Required Signatures in Section 7
The form requires signatures from both the patient (or representative) and the member, which can be confusing if they are the same person. People often sign only one line, rendering the form legally incomplete. A missing signature invalidates the authorization to release information, causing the claim to be returned unprocessed. To avoid this, ensure both signature lines are signed and dated, even if the same person is signing twice.
Confusing 'Member' and 'Patient' Information
Users sometimes fill in the patient's information in the 'Member' section (Section 1), especially when the patient is a dependent. The 'Member' is always the primary subscriber on the insurance plan. This mistake can cause record-matching failures and processing delays. To prevent this, always complete Section 1 with the subscriber's information from the ID card, and Section 2 with the details of the person who actually received the medical care.
Using Incorrect Date Formats
The form specifies the MMDDYYYY format for all dates, but people frequently add slashes (MM/DD/YYYY) or use a different order out of habit. While it seems minor, this can cause data entry errors on the processor's end or be flagged by automated systems, delaying the claim. Pay close attention to the format instructions next to each date field. Using a tool like Instafill.ai can help by automatically formatting dates correctly as you type.
Incomplete or Inaccurate 'Other Insurance' Information
When a patient is covered by more than one plan, coordination of benefits is required. People may check 'No' in Section 5 to save time or because they are unsure, which can lead to claim denials or even accusations of fraud. If other insurance exists, it must be reported with accurate policyholder and policy number details. This ensures the primary and secondary payers are correctly identified, preventing delays and rejections.
Vague Description of Illness or Injury
In Section 3, a patient might write a generic description like 'stomach pain' or 'check-up.' This lacks the specificity needed for a claims adjuster to process the claim, which relies on matching the diagnosis to the services provided. This ambiguity forces the insurer to request more information, causing significant delays. It is best to use the specific diagnosis provided by your doctor, which can be found on the itemized bill or patient summary.
Using Nicknames or Incorrect Legal Names
A person may enter 'Mike' instead of 'Michael' or forget to include a suffix like 'Jr.' This creates a mismatch between the name on the claim and the name in the insurer's database. This discrepancy can cause the claim to be flagged for identity verification, delaying payment. Always use the full, legal name of the member and patient exactly as it appears on the insurance ID card.
Incorrectly Filling Out Work-Related Injury Section
People may be unsure if an injury qualifies as work-related and mark 'No' in Section 4 to avoid complexity. However, if an injury occurred at work, workers' compensation is typically the primary payer, not health insurance. Incorrectly routing the claim can lead to it being denied and requiring resubmission through the correct channels, causing major delays and potential billing issues for the member. If an injury is even possibly work-related, it should be marked 'Yes' and the employer details provided.
Submitting a Scanned, Non-Fillable PDF
Often, these forms are available only as flat PDFs, which users print, fill by hand, and then scan. Handwritten information can be illegible, leading to data entry errors and processing delays. Furthermore, the user has no way to save a digital copy easily. Tools like Instafill.ai can convert non-fillable PDFs into interactive, fillable forms, ensuring all entries are clear, legible, and can be saved digitally, which helps prevent many of the other common errors.

Frequently Asked Questions About 114027NYMENABC

 

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How does the AI fill out 114027NYMENABC?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of 114027NYMENABC, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is 114027NYMENABC to fill out?
114027NYMENABC has a Form Complexity Index of 53 out of 100, in the moderate tier: 47 fillable fields across 1 page. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
When should I use this Anthem Blue Cross Claim Form?
You should use this form to request reimbursement for medical services when your doctor or healthcare provider does not file the claim directly with Anthem on your behalf.
What documents do I need to submit with this claim form?
You must attach a complete, itemized bill from your provider. The bill needs to include the provider's name and tax ID, patient's name, date and type of service, diagnosis, and the amount charged.
What is the difference between 'Member Information' and 'Patient Information'?
Member information refers to the primary subscriber of the insurance plan. Patient information is for the person who actually received the medical care, who could be the member, their spouse, or a dependent.
Where do I send the completed claim form?
Mail the signed form and your itemized bill to Anthem Blue Cross, P.O. Box 1407, Church Street Station, New York, New York 10008–1407.
Can I use one form to file claims for multiple family members?
No, you must complete and submit a separate claim form for each family member who received services.
Who signs the form if the patient is a minor?
If the patient is a minor, their parent or legal guardian must sign the form in the 'Patient signature' field in Section 7.
What if the patient is also covered by another health insurance plan?
You must complete Section 5 with details about the other insurance policy. This is necessary for the coordination of benefits between the two insurance companies.
Why does the form ask if an injury was work-related?
This information helps determine if workers' compensation should be the primary payer for the claim. If it was work-related, you must provide your employer's details in Section 4.
Where can I find my Member Identification Number?
Your Member Identification Number is printed on your Anthem Blue Cross ID card. This number is required to process your claim, so ensure it is entered correctly in Section 1.
Is there a deadline for submitting this claim form?
Yes, you should submit the claim as soon as possible after receiving care. Check your specific certificate of coverage for the exact deadlines for claim submission.
Can I use an AI tool to help me fill out this claim form?
Yes, services like Instafill.ai use AI to accurately auto-fill form fields from your saved information, which can save you time and help reduce errors.
How can I use Instafill.ai to complete this form online?
Simply upload the claim form to the Instafill.ai platform. The AI will identify the fields, allowing you to use your saved profile to fill in your information with a single click.
What should I do if the PDF version of this form is not fillable?
You can use a service like Instafill.ai, which can convert flat, non-fillable PDFs into interactive, fillable forms online. This allows you to type your information directly into the fields before printing.
Why do I need to provide my Medicare information in Section 6?
If you are covered by Medicare, Anthem needs this information to correctly coordinate benefits between the two plans. You must provide your Medicare claim number and the effective dates for any parts you are enrolled in.
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