Forms
- Claims Form
- Empire Claim Form
- Authorization for Use or Disclosure of Medical Information
- Autorización para que Carelon Behavioral Health divulgue información confidencial
- CMS-1500 Claims Form
- Outpatient-Review-Form
- Frequently Asked Questions
- Confidential Communication Request Form – California Only (Online)
- Confidential Communication Request Form – California Only (Printable)
Resources
- Claim Submission
- Mental Health Parity Disclosures for Members in New York
- Out-of-Network Emergency Services and Surprise Bills (NY only)
- No Surprise Bills
Carelon Behavioral Health uses the ASAM Patient Placement Criteria to make authorization determinations for Substance Use Care. If you have questions about a determination for Substance Use Care, click the link below.
Carelon Behavioral Health uses Medical Necessity Criteria to make authorization determinations for Mental Health Care. If you have questions about a determination for Mental Health Care, click the link for the level of care that applies below.
To obtain the complete ASAM medical necessity criteria for a specific level of care, please contact customer service at the number on the back of your ID card.
Carelon Behavioral Health uses Carelon Behavioral Health Medical Necessity Criteria to make certain public sector authorization determinations for Mental Health Care in New York. If you have questions about a determination for Mental Health Care, click the link for the level of care that applies below.