Chinatown East New York Mental Health Claims Home Live Well Mental Health Mental Health Claims How to Submit Your Mental Health or Substance Use Disorder Claim In most cases, if you choose to see an in-network provider, you have a cost-share such as a copay, or a set amount you pay per visit. An in-network provider is a health care professional or facility that contracts with EmblemHealth and ConnectiCare. They provide covered products and services to members. You'll usually pay less when you use doctors, hospitals, and others in the network. If you choose to get care with an out-of-network mental health provider, you may still get reimbursed,* or repaid, for some of your out-of-pocket costs. To get reimbursed, you must download these materials, including a claim submission form. Then, follow the steps below: After your next session, have your provider fill out Part II of the form and give it back to you. Under Assignment of Benefits, check off the “No” box. Sign and date your name in the three locations indicated. Fill out Part I of the form completely. Do not leave anything blank. Instructions for Mailing If you plan to mail your form and see your provider regularly, have your provider fill out the form once and make multiple copies of it. You will need to submit a claim for each visit. Mail your form to the address on your member ID card. Instructions for Online Submission If you plan to submit your form online, be sure to save your form in a safe location on your computer. Submit your claim online, following the prompts. Be sure to have your member ID number handy. You will need to have your form saved on your computer, so you can upload it to the submission portal. For questions on submitting your claim or help for a mental health issue, please call Beacon Health Options at 888-447-2526 for confidential, 24/7 support. *Not all health plans include reimbursement. Please check your benefit details. To confirm eligibility, call the number on your member ID card. Find a doctor or medical office Why EmblemHealth Find a Doctor Our Plans Member Resources Live Well Individual & Family Medicare Advantage Medicare Supplement Medicaid, HARP, and CHPlus (State-Sponsored Programs) News and Updates Featured Events Events Pharmacy Payments and Accounts Blog Contact Us Locations Neighborhood Care Legal Information Careers myEmblemHealth Member Portal Sign In Legal Accessibility Statement EmblemHealth Privacy & Security Policies Nondiscrimination Policy Stop Fraud Interoperability Information LANGUAGE ASSISTANCE: Español 中文 Pусский Kreyòl 한국어 Italiano אידיש বাংলা Polski العربية Français اردو Tagalog Ελληνικά Shqip ©2021 EmblemHealth. All Rights Reserved. Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.