Disputing Claims for Out-of-Network Emergency Services or Surprise Bills with Carelon Behavioral Health

If you disagree with how we processed a claim because you believe the bill was for out-of-network emergency services or a surprise bill, you can do either or both of the following:

• Call Carelon Behavioral Health Customer Service and tell us you think your claim was for emergency services or is a surprise bill. Please contact the phone number for behavioral health (mental health/substance use) on your ID card. For a surprise bill, you will be required to complete and submit the standard surprise bill Assignment of Benefits Form, plus a copy of the bill you received from your provider. For a surprise bill, you can also simply complete and submit the standard surprise bill Assignment of Benefits Form to Carelon Behavioral Health and to your provider without calling and we will re-evaluate your claim. To submit the information noted in this paragraph, please see below.
  

  Mail	PO Box 1851 Hicksville, NY 11802
  Fax	(855) 378-8309
  Email	nysurprisebill@carelonbehavioralhealth.com

• Submit a dispute by mail or fax. To file a grievance concerning a claim, please see below.
  

  Mail	PO Box 1851 HIcksville, NY 11802
  Fax	(855) 378-8309