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  • Value Options Claim Forms 2003

Get Value Options Claim Forms 2003-2025

PLAN (SSN or ID) CHAMPVA (Member ID#) 3. PATIENT S BIRTH DATE MM DD YY 2. PATIENT S NAME (Last Name, First Name, Middle Initial) OTHER 1a. INSURED S I.D. NUMBER FECA BLK LUNG (SSN) (ID) 4. INSURED S NAME (Last Name, First Name, Middle Initial) SEX M 5. PATIENT S ADDRESS (No., Street) F 6. PATIENT RELATIONSHIP TO INSURED Self CITY STATE Child Spouse 8. PATIENT STATUS STATE CITY Married Other Employed Full-Time Student Part-Time Student TELEPHONE (Include Area Co.

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Group Health Incorporated (GHI), Health Insurance Plan of Greater New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies.

To submit electronic claims, sign in to our secure provider Web site or register to start an account. Our Electronic Payer ID is 13551. To submit claim attachments, such as X-rays, we recommend using FastAttach, a system of National Electronic Attachment (NEA).

Behavioral health services for members in plans underwritten by HIP or in ASO plans administered by VHMS are administered by Beacon Health Options under the Emblem Behavioral Health Services Program.

Effective January 1, 2016, EmblemHealth's behavioral health and substance use vendor, ValueOptions, will be known as Beacon Health Options. This is a change in name only; all benefit and contact information remains the same. So, if you receive anything from Beacon Health Options, please be sure to open and read it.

Electronic Claims Submission and Clearinghouses Submissions must reference Payer ID, CARELON BEHAVIORAL HEALTH 963116116, to ensure Carelon Behavioral Health of California receives those claims.

Carelon is the name of Elevance's health service division. This comes roughly three years after Elevance Health, previously Anthem, purchased behavioral health operator Beacon.

Electronic claims submission vs. manual claims submission A “manual claim” is a paper claim form that refers to either the Centers for Medicare & Medicaid Services CMS-1500 form (formerly HCFA-1500) or a Uniform Billing UB-04 form, both of which are typically sent to the payer through the mail and require postage.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232