Anthem 2FA EOB Concierge Enrollment Form: ACES

This is step 1 of 2. You will need to respond to the confirmation email with your username and password as a 2-step authentication.

Plan Member,

Your employer may have chosen to enroll you in MaxMed105’s EOB CONCIERGE PROGRAM. Traditionally, a MaxMed105 member is required to send all insurance company’s Explanation of Benefits (EOB’s) to eba&m. With the EOB CONCIERGE PROGRAM this step will be done for you. To do this, eba&m will utilize the insurance company’s website to make a weekly sweep for each members’ EOB’s.

Access to the insurance company’s website is given to you, the member. To enroll in the EOB CONCIERGE PROGRAM, you will have to register online and then provide eba&m with your user name and password. DUE TO PRIVACY REGULATIONS, EACH MEMBER OF YOUR FAMILY MUST CREATE THEIR OWN LOGIN.

To register, please go to your insurance company’s website. Follow their instructions to register as a user. After completing the registration, fill in your user name and password on this form. It is very important that you clearly indicate the correct user name and password, including upper and lower case letters.

Please keep in mind that it is your responsibility to provide us with your user name and password. If you fail to do so, or choose not to provide it to us, we cannot retrieve your EOB’s and it will be YOUR RESPONSIBILITY to send them in to eba&m! If for any reason your login information changes it is your responsibility to provide eba&m with the updated information. If your employer did not sign up for the EOB Concierge program, you must send in your EOB’s to eba&m Corporation for your claim to be processed.

Employer*

Employee Name*

First NameLast Name

Member Name

First NameLast Name

Member Email*

example@example.com

Security Question 1*

Security Question 1

Answer to Security Question 1*

Security Question 2

Answer to Security Question 2*

Security Question 3

Answer to Security Question 3*

Security Question 2*

Security Question 3*

I understand that submitting this form is not a guarantee of coverage. I understand that enrollment in the EOB CONCIERGE PROGRAM is voluntary and I can cancel my participation at any time. By clicking the "Enroll" button below, I authorize EBA&M to receive protected health information about me in order to assist me in the filing of my MaxMed105 claims.