<p> Anthem Balanced Funding </p><p>New Anthem Balanced Funding Client Set-up Requirements and Forms (may also be used for existing clients who request banking changes)</p><p>Anthem Blue Cross Finance associates are pleased you have chosen a self-funded arrangement where we will be servicing your account for claims payment. Since it will take approximately 2 weeks to complete the set-up process, prompt receipt of the completed documents are necessary to ensure a smooth, timely implementation and proper administration of the self-funded account. Please email or mail the completed documents to:</p><p>Rashida Christian, Manager CA ASO Billing Anthem Blue Cross 21555 Oxnard Street Woodland Hills, CA 91367 Mail Stop: CAAC10-010E Email address: [email protected] Phone number: 818-234-3531 Fax number: 818-234-3760</p><p>The subsequent pages will outline the rest of the set-up process; however, if you need clarification on any of the forms, please contact the associate for assistance. Your Account Executive may also be contacted:</p><p>Financial Oper Patricia Oh Consultant 818-234-4484 [email protected]</p><p>Anthem Blue Cross Page 1 of 5 ASO Billing Sept 2012 CP</p><p>Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Balanced Funding</p><p>REQUIRED DOCUMENT #1 ELECTRONIC FUNDS TRANSFER (EFT) FORM</p><p>PURPOSE: Allows Anthem Blue Cross to electronically debit the client’s bank account for claims.</p><p>REQUIREMENTS: The client must submit the EFT form to Anthem with the other documents.</p><p>IMPACT: Anthem cannot process EFT debits to the client’s bank account, which will delay claims payments.</p><p>EFT FORM: Please double click the icon to access the form: </p><p>EFT Form ABF_CA.pdf</p><p>Anthem Blue Cross Page 2 of 5 ASO Billing Sept 2012 CP</p><p>Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Balanced Funding</p><p>REQUIRED DOCUMENT #2 CLIENT INFORMATION WORKSHEET</p><p>PURPOSE: Provides detailed information to Anthem Blue Cross regarding client and bank.</p><p>REQUIREMENTS: All requested information must be filled in. Only options provided on the worksheet are available to the client.</p><p>IMPACT: Anthem Blue Cross will not have sufficient information to set up the client’s funding arrangement. This may delay claims payments.</p><p>NOTE: Please refer to the Client Information Worksheet on the next page.</p><p>Anthem Blue Cross Page 3 of 5 ASO Billing Sept 2012 CP</p><p>Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Balanced Funding</p><p>CLIENT INFORMATION WORKSHEET</p><p>1. EMPLOYER INFORMATION Name of Employer Group: Business Address: Contact Name: (Who will oversee the set-up process?) Phone Number: Fax Number: Email Address: Employer ID# (EIN) or Tax ID #:</p><p>2. EMAIL INSTRUCTIONS FOR BANK ACCOUNT ACTIVITY The purpose of this section is to provide email instructions to Anthem Blue Cross to notify the client of ACH debit activities. The email communication will not contain any PHI. </p><p>PHONE RECIPIENT NAME EMAIL ADDRESS NUMBER</p><p>Anthem Blue Cross Page 4 of 5 ASO Billing Sept 2012 CP</p><p>Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association. Anthem Balanced Funding</p><p>REQUIRED DOCUMENTS CHECK LIST</p><p>1. Is the EFT authorization letter signed and attached? YES NO, DATE EXPECTED: </p><p>2. Is the client information worksheet attached? YES NO, DATE EXPECTED: </p><p>Anthem Blue Cross Page 5 of 5 ASO Billing Sept 2012 CP</p><p>Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.</p>