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It specifies completion requirements for Parts I and II, highlights required (bold) fields, explains how to complete items related to patient demographics, identification numbers, other coverage, Medicare eligibility, authorization to pay, and signatures. It also instructs providers to include required clinical details such as diagnoses using ICD-10-CM or DSM V codes, and outlines additional documentation and scanning-friendly formatting.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/mental-healthsubstance-use-treatment-claim-form-directions-for-completion/288440/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/mental-healthsubstance-use-treatment-claim-form-directions-for-completion/288440.png","ImageObject",442,249,{"name":88,"@type":89},"Kyle","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What do I need to complete to ensure the claim is processed for payment?","Question",{"text":108,"@type":109},"Complete Parts I and II in their entirety, with special attention to fields shown in bold, since those are required for payment consideration.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Who must complete which part of the claim form?",{"text":113,"@type":109},"The participant/patient completes Part I, and the attending provider must complete Part II. If the provider uses a custom form, Box 7 under Part II must still be completed.",{"name":115,"@type":106,"acceptedAnswer":116},"What diagnosis information is required on Part II?",{"text":117,"@type":109},"Part II must include a medically accepted diagnosis, entered as a valid ICD-10-CM or DSM V diagnosis code, including the additional digits when applicable, with up to three diagnoses allowed.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288440,1790144803,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":73},3985741905716,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Mental Health/Substance Use Treatment Claim Form  \nDIRECTIONS FOR COMPLETION  \nIf you are in treatment with a non-participating Carelon Behavioral Health, inc. (Carelon) providerandyour provider has indicated that you will be responsible to file your claim, please take this claim form with you to your visit.  \nIn order to facilitate payment of your claim, please be sure that Parts I and II are completed in their entirety. An explanation of each field is provided below. The fields in BOLD lettering are required in order for the claim to be considered for payment.  \nYou must complete Part I in its entirety.  \nYour provider must complete Part II in its entirety. Even if your provider provides you with their custom claim form, Beacon requires that they complete Box 7 under Part II. If you are unable to get the signature of the provider, please print his/her name in Box 7, Part II. Please be sure that as much of Part II is completed as possible. You may attach yourprovider’s custom claim form for our review.  \nPlease make every effort to have this form printed in red ink. Please use a black ballpoint pen when filling in the required fields. This allows the claim to be scanned through technology that expedites the claims payment process. (However, black and white forms are accepted.)  \nPART I: To Be Completed By Participant/Patient (Required fields are in BOLD lettering)  \n1. PATIENT'S NAME-Enter the Patient’s name (Last, First Name, and Middle Initial) . Spell the name exactly as it appears on the subscriber/patient’s identification card.  \n2. PATIENT'S ADDRESS-Enter the Subscriber/Patient’s permanent address (Street, Apartment/PO Box Number, City, State, Zip Code) .  \n3. PATIENT’S ID NUMBER-Enter the Subscriber/Patient’s 9-digit ID number. This number appears on the Patient’s insurance card.  \nNote: If this item is blank, the claim will be returned for this information.  \n4. PATIENT'S BIRTH DATE-Enter the Patient's date ofbirth.  \n5. PATIENT’S SEX-Put an X in the appropriate box to indicate the Patient's sex.  \n6. PATIENT RELATIONSHIP TO SUBSCRIBER-Put an X in the appropriate box to indicate the Patient’s relationship to the Subscriber.  \n7. PARTICIPANT’S NAME-If different than Patient.  \n8. PARTICIPANT’S MEMBER ID NUMBER-Enter the Subscriber’s Member ID Number or Medicaid Number (if different from \\#3) .  \n8a. EMPLOYER NAME/GROUP NUMBER-Enter the Subscriber’s Employer name. If the Employer’s group number is available on the card, please also provide.  \nOTHER MENTAL HEALTH/SUBSTANCE USE COVERAGE  \n(This information is important if the Patient is covered under other group insurance. Even if the Patient is not covered under other group insurance, please answer question \\#9.)  \n9. IS THE PATIENT COVERED BY ANY OTHER GROUP INSURANCE PLAN? -Put an X in the appropriate box.  \nIf there is no other insurance coverage, you do not have to answer the following questions:  \n• NAME OF OTHER INSURANCE COMPANY  \n• CARD NUMBER-This is the identification number assigned to the Subscriber by the other insurance company.  \n• ADDRESS OF OTHER INSURANCE COMPANY-Enter address of the other insurance carrier as it appears on the identification card.  \nNOTE: The other insurance carrier must be billed for these services. When you receive the Explanation of Benefits from the other insurance carrier, you should attach it to this claim form. Attach it even if the other insurance carrier does not pay anything on the services.  \n10. MEDICARE ELIGIBLE-Place an X in the appropriate box.  \nIf“Yes” complete the following:  \nPART A-EFFECTIVE DATE-Month, Day and Year  \nPART B-EFFECTIVE DATE – Month, Day and Year  \nASSIGNMENT OF BENEFITS  \n(This information is very important to assure any payment on the claim goes to the appropriate party, either to the member or the provider.)  \n11. HAS THE PROVIDER BEEN PAID-Put an X in the appropriate box. If you answer “Yes” to this question, please make sure that the amount paid is recorded in Box 9, Part II, Amount Paid.  \n11a. ","cbCaicI7KJWZutgn","https://ap.wps.com/l/cbCaicI7KJWZutgn","pdf",244980,"English","# DIRECTIONS FOR COMPLETION\n## Part I: To Be Completed By Participant/Patient\n## OTHER MENTAL HEALTH/SUBSTANCE USE COVERAGE\n## ASSIGNMENT OF BENEFITS\n## Part II: To Be Completed By Attending Provider","[{\"question\":\"What do I need to complete to ensure the claim is processed for payment?\",\"answer\":\"Complete Parts I and II in their entirety, with special attention to fields shown in bold, since those are required for payment consideration.\"},{\"question\":\"Who must complete which part of the claim form?\",\"answer\":\"The participant/patient completes Part I, and the attending provider must complete Part II. If the provider uses a custom form, Box 7 under Part II must still be completed.\"},{\"question\":\"What diagnosis information is required on Part II?\",\"answer\":\"Part II must include a medically accepted diagnosis, entered as a valid ICD-10-CM or DSM V diagnosis code, including the additional digits when applicable, with up to three diagnoses allowed.\"}]","Mental Health/Substance Use Treatment Claim Form - Directions for Completion | PDF",1789633487]