You may use your own standard claim form; however the HCFA 1500 claim form is preferred. When submitting claims please send the original and include all elements below to avoid claims pending:

• Patient name and ID number
• Subscriber name (if different than patient) and ID number
• Date(s) of service
• DSM-IV code for diagnosis
• Service provided and CPT code(s)
• Place of service
• Amount charged
• Employer name and group number
• Name, address, phone number, and tax ID number of provider
• Provider's signature

Timely Filing Period
Claims for covered services should be submitted within 30 days of the date of service, and no later than 60 days following the date of service. Claims that are not submitted within this filing period will not be honored for payment. Reconsideration, resubmission or any follow-up must be identified clearly and submitted within one year from the date of service.

Common Billing Errors
Following are the most common mistakes providers made in submitting claims, resulting in pending claims and delayed payment:

• Patient name/ID number does not match the patient name/ID number for the authorization. For example, the provider's office bills under the employee or parent, when the authorization/referral was designated for the child.
• Incorrect date(s) of service. The date(s) of service occured outside the date range given on the authorization.
• The procedure code on the claim does not match the procedure code on the authorization.
• Charge amounts are missing.
• Provider name or Tax ID number does not match authorization.
  • You may have different locations with different Tax ID numbers for each and used the wrong one on the claim.
  • You may have changed your Tax ID but forgot to notify BHO.
  • You may have seen the patient for another provider for whom the authorization/referral was made.
• Claims are sent to the incorrect address. If you have questions on where to send your claim, please refer to your provider manual or call our claims department at (877) 393-6094 ext. 8741.
• For EAP claims, the EAP data form is missing.