If you receive a bill for out-of-network emergency services or you receive a surprise bill for out-of-network services, you should contact us. If it’s a surprise bill, the out-of-network provider must provide you with a surprise bill Assignment of Benefits Form as well.
If you “assign benefits” for a surprise bill in writing to an out-of-network provider who knows you’re insured under a health care plan, that provider cannot seek payment from you — except for any in-network cost-sharing (in-network copayment, coinsurance and/or deductible) that applies to the service under the terms of your plan.
If you receive a surprise bill for out-of-network services and you want to assign benefits, send Carelon Behavioral Health the following documents:
- Standard Assignment of Benefits Form (only surprise bills)
- Claim form
- Copy of the bill
Documentation can be sent to one of the following:
PO Box 1851
Hicksville, NY 11802
Fax (855) 378-8309 firstname.lastname@example.org
- Upon receiving this information, we will process a claim for the related services. You must also submit a copy of the Assignment of Benefits form to your provider.