Anthem BlueCross Medi-Cal Managed Care Behavioral Health Form
This file is a request form for Behavioral Health Out of Network Outpatient Treatment under Anthem Blue Cross Medi-Cal Managed Care. It is used to seek authorization for out-of-network behavioral health services. Complete and submit the form to avoid delays in processing.
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How do I fill this out?
To fill out this form, you will need to provide comprehensive information about the patient, provider, medical history, and treatment plans. Ensure all fields are completed accurately. Incomplete or illegible forms will delay processing.
How to fill out the Anthem BlueCross Medi-Cal Managed Care Behavioral Health Form?
1
Gather all necessary patient and provider information.
2
Complete the Member Information section with patient details.
3
Fill in the Provider Information section with servicing provider's details.
4
Detail the patient's medical history and treatment goals in the respective sections.
5
Submit the completed form via fax or online submission.
Who needs the Anthem BlueCross Medi-Cal Managed Care Behavioral Health Form?
1
Patients seeking out-of-network behavioral health services under Anthem Blue Cross Medi-Cal Managed Care need this form to request authorization.
2
Providers who are out-of-network under Anthem Blue Cross Medi-Cal Managed Care use this form to provide necessary patient treatment details.
3
Care coordinators assisting patients with their behavioral health needs may utilize this form for seamless communication and approval processes.
4
Primary care physicians coordinating with behavioral health providers use this form to ensure proper treatment continuity.
5
Healthcare administrators processing claims and authorizations under Medi-Cal Managed Care plans require this form for accurate record-keeping.
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Use the provided editing tools to fill in all required sections.
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Save your changes directly within the editor.
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Download the edited PDF for submission or record-keeping.
What are the instructions for submitting this form?
Submit the completed form via fax to 855-473-7902 or through the online submission form available on the Anthem Blue Cross provider portal at https://providers.anthem.com/ca. Ensure all fields are accurately completed to avoid processing delays. For any questions or assistance, contact 888-831-2246. My advice is to review all information carefully before submission to ensure completeness and accuracy.
What is the purpose of this form?
The purpose of this form is to request authorization for out-of-network behavioral health outpatient treatment under Anthem Blue Cross Medi-Cal Managed Care. It is used by patients and providers to ensure necessary treatment is approved and coordinated effectively. By completing this form, all involved parties can facilitate timely and accurate processing of treatment requests.
Tell me about this form and its components and fields line-by-line.
- 1. Member Information: Includes patient name, date of birth, address, phone number, and Medi-Cal ID number.
- 2. Provider Information: Contains details of the direct servicing provider including name, credentials, contact information, NPI, and Tax ID number.
- 3. Medical History: Requires information on the patient's substance use history, prior treatments, and hospitalizations.
- 4. Treatment Goals: Asks for information on the primary complaint, measurable treatment goals, and assessments used.
- 5. Primary Care Physician Communication: Confirms whether information has been shared with the primary care physician and other relevant providers.
- 6. Current Risk/Lethality: Assesses the patient's risk levels related to suicidal, homicidal, and assault/violent behaviors.
- 7. Community-Based Support: Inquires about the patient's involvement in community-based support groups or interventions.
- 8. Coordination of Care: Checks if care coordination with other behavioral health or medical providers has been established.
- 9. Medication Details: Documents the prescriber of medications and whether evaluations have been done by psychiatrists or primary care physicians.
What happens if I fail to submit this form?
Failure to submit this form can result in delays or denial of authorization for out-of-network behavioral health services. Ensure all parts of the form are filled out accurately and submitted promptly.
- Delayed Processing: Incomplete or inaccurate forms can lead to significant delays in processing and obtaining authorization.
- Denial of Services: Missing or incorrect information may lead to denial of the requested behavioral health services.
- Lack of Treatment Continuity: Failure to submit the form can disrupt the continuity of care and treatment plans for the patient.
How do I know when to use this form?
- 1. Out-of-Network Service Request: When the required behavioral health provider is not within the Anthem network.
- 2. Authorization for Specialized Care: To obtain approval for specialized behavioral health treatments that are not available in-network.
- 3. Continuity of Care: To maintain continuity of care with a provider not currently contracted within the Anthem network.
- 4. Geographical Limitation: When in-network providers are not available in the patient's geographical area.
- 5. Provider Specialty Requirement: When a specific clinical specialty is needed that is not available in-network.
Frequently Asked Question
How do I fill out this form?
You can fill out the form by entering patient, provider, and medical information in the respective fields. Make sure all information is accurate to avoid processing delays.
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What information is required in the Member Information section?
The Member Information section requires patient details such as name, date of birth, address, phone number, and Medi-Cal ID number.
What should be included in the Provider Information section?
The Provider Information section should include the name and credentials of the servicing provider, their contact details, NPI, and Tax ID number.
How do I provide medical history on the form?
In the Medical History section, provide details of the patient's substance use, inpatient and outpatient treatments, and any relevant hospitalizations.
What are the treatment goals?
The treatment goals section should list the primary complaint, measurable treatment goals, and standardized assessments used with their scores.
How do I know if the patient is ready to terminate treatment?
In the Discharge Goals section, describe how you will determine if the patient is ready to terminate treatment based on progress and outcomes.
Are there any additional steps after completing the form?
After completing the form, submit it via fax or through the online submission portal provided by Anthem Blue Cross for further processing.
