What to Do If You Get a Bill for Out-of-Network Emergency Services or a Surprise Bill

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:

  1. Standard Assignment of Benefits Form (only surprise bills)
  2. Claim form
  3. Copy of the bill
    Documentation can be sent to one of the following:

    Mail PO Box 1851
    Hicksville, NY 11802
    Fax (855) 378-8309
    Email nysurprisebill@carelon.com
  4. 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.