EAP Form Anthem PDF Details

Navigating the complexities of health care and wellness support can seem daunting, but forms like the Employee Assistance Program (EAP) Statement of Services Rendered play a pivotal role in ensuring the process unfolds smoothly. This document is integral for health providers working under the EAP, detailing critical information like provider names, National Provider Identifier (NPI) numbers, billing addresses, and much more. Unique to this form is the adherence to HIPAA privacy regulations, notably the mandate forbidding the inclusion of EAP member’s names directly on the forms, a provision aimed at safeguarding patient confidentiality. Moreover, the form serves as a bridge between health professionals and the Anthem EAP, providing scheduled appointment dates, the range of sessions provided, and instructions for submitting claims. It is, in essence, the backbone of EAP-oriented transactions, simultaneously prioritizing patient confidentiality while ensuring providers have a clear and structured method to report services and arrange for payments. The document underscores the importance of confidentiality warnings and adheres to the rigors of federal and state laws regarding patient information, delivering a comprehensive tool for managing EAP claims and services.

QuestionAnswer
Form Name EAP Form Anthem
Form Length 4 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 1 min
Other names anthem eap billing form, anthem eap provider, eap anthem bcc, eap services rendered anthem form

Form Preview Example

EAP STATEMENT OF SERVICES RENDERED FORM

Confidential Health Information

Provider Name:

Rendering Provider National Provider Identifier (NPI):_______________________________________

Fax Number:

Billing Address:

___________________________________________________________

 

___________________________________________________________

Make Check Payable to:

___________________________________________________________

Tax ID:

___________________________________________________________

Billing Provider National Provider Identifier (NPI):__________________________________________

Reference Number:

(Required)

Important Note for Providers due to HIPAA privacy regulations we can no longer include any EAP member’s name on these confirmation forms. We will only release the member name telephonically.

For the member name that corresponds to the reference number, please feel free to contact Anthem EAP at the toll free number located in the "From:" box on the fax cover sheet.

Scheduled Appt Date (Date Reported by Client):

(Reminder: please call (800) 728-9492, Option 1# and report first session date)

Start Date:

 

End Date:

Company:

 

EAP Model:

 

 

 

 

Sessions Provided:

 

 

 

Date

 

 

Date

#1 _______________

 

#7

________________

#2 _______________

 

#8

________________

#3 _______________

 

#9

________________

#4 _______________

 

#10 ________________

#5 _______________

 

#11 ________________

#6 _______________

 

#12 ________________

Provider Signature: __________________________________ Date: __________________

 

 

 

 

Mail Claims to: EAP Claims

 

 

 

9655 Granite Ridge Drive, 6

th

Floor

Or Fax to: (858) 571-8102

 

 

San Diego, CA 92123

 

 

For Claim Status: (800) 728-9492 Option 3#

 

 

 

 

Confidential Health Information Enclosed

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately and destroy the related message. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without appropriate patient consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in Federal and State law.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

EAP CASE FORM

Phone (800) 728-9492, Option 2# Fax (858) 571-8102

Confidential Health Information

Client Name:

 

 

 

 

Reference # (Required):

Company:

EAP Assessment: (Check 1 box only)

 

 

 

 

Alcohol

 

 

 

 

Marital/Couple Problem

Drug

 

 

 

 

 

Violence

Impacted By Alcohol Family/Significant Other

Medical Problem

Impacted by Drug Family/ Significant Other

Legal

Emotional/Psychological

 

 

 

Financial Problem

Impacted by Emotional/Psych of Family/ Significant Other

Work Related Concern

Eating Disorder

 

 

 

 

Dependent Care

Family Problems

 

 

 

 

Other Issues

 

 

 

Recommendation: (Primary) (Check 1 box only)

 

 

EAP only

 

 

 

 

Partial hospital psychiatric

Medical doctor referral

 

 

 

Outpatient mental health (office)

Psychiatric meds. Eval/tx

 

 

 

Psychological testing

Alcohol/drug detoxification

 

 

Social agency, public program/mental health

Inpatient alcohol/drug tx

 

 

 

Self-help/support group

Structured outpatient alcohol/drug tx

 

 

Employer, H.R., management, benefits, etc.

Non Hospital Residential Facility

 

 

Childcare/eldercare resources

Inpatient psychiatric tx

 

 

 

Career / vocational counseling

 

 

 

 

 

 

 

Closing Date:

 

 

 

 

 

 

 

 

 

Benefit Utilization:

EAP Assistance Only

Referrals Not Utilizing Insurance Benefits (Community Resources)

 

Referrals Utilizing Insurance Benefits

 

 

 

 

 

 

 

 

Referral Information

 

 

 

 

 

 

The Client Was Referred to:

 

 

 

 

 

Psychiatrist

Psychologist

MFT/LCSW

Community Resources (Referrals Not Utilizing Insurance Benefits)

PCP/Medical Specialist

Other

Case Closed (EAP Assistance Only/No Additional Referral Needed)

If care was transferred to another licensed professional or behavioral health facility, was the transfer of care coordinated with the new provider by:

Phone

Fax

Report/Letter

Other

Not Applicable

 

 

 

 

 

 

Disposition of Case:

Resolved

Improved

No Change

Deteriorated

 

 

Declined Recommendation

Unable to Contact

Confidential Health Information Enclosed

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this information is STRICTLY PROHIBITED. If you have received this message by error, please notify us immediately and destroy the related message. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without appropriate patient consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in Federal and State law.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

EMPLOYEE ASSISTANCE PROGRAM (EAP) PARTICIPANT ORIENTATION

Please read thoroughly before signing and direct any questions to your consultant.

DESCRIPTION OF SERVICES: Your company has contracted with Blue Cross of California (BCC) to provide professional consultation for

employees and their family members regarding a wide range of personal problems. Available services may include: assessment, short-term counseling, and referral. If longer term counseling or specialized services are needed, BCC will refer you to qualified professionals or organizations in the community. BCC will then follow up to assure that your needs are being met. Certain insurance plans require EAP referral in order to utilize your mental health and substance abuse benefits.

FEES: There are no fees to employees or family members for any service received directly from BCC. When BCC refers to resources in the community for ongoing or specialized services, you are responsible for paying any applicable fees. Your group health plan may or may not cover some of the cost of referred services. If BCC makes a referral that utilizes your company benefits, it is your responsibility to verify both your insurance eligibility and the benefits available for behavioral health. This can be done by contacting either the insurance company or your benefit department. It will also be your responsibility to ensure that any provider to whom BCC may refer you is a provider who is consistent with your insurance plan.

CONFIDENTIALITY: When an individual utilizes EAP services, all information will be held confidential unless: 1) the individual authorizes release of information with a signature; 2) the individual represents, in the EAP consultant's opinion, a physical danger to self or others; 3) child abuse/neglect, elder abuse/neglect, or dependent adult abuse/neglect is suspected; 4) a court order for records is issued. If you are employed by a company contracted with or regulated by the Departments of Defense or Transportation or the Nuclear Regulatory Commission, BCC may be required to disclose information about your EAP consultation under the following conditions: a) there is a significant breach of security or safety policies, b) BCC receives an administrative summons or judicial subpoena or order, c) you were referred due to a positive drug test, d) as further defined by your employer. BCC does not make routine "adverse information" reports.

VOLUNTARY PARTICIPATION: The decision to participate in the EAP is voluntary in most cases. Employees participating in the program should not expect any special privileges or exceptions to normal work rules or performance standards. EAP participation is not to be interpreted as constituting a waiver of management's rights to take disciplinary measures, nor shall the program be interpreted as a waiver of the right of any employee to use a complaint procedure within the framework of company policies.

EMPLOYER REFERRAL: When an employee is referred to the EAP by the employer, the appropriate company representative of the

organization may be advised with the employee's consent if: 1) the employee kept the appointment; 2) the EAP consultant has made recommendations; 3) the employee has agreed to follow these recommendations.

GRIEVANCE PROCEDURE: If you are dissatisfied with the service you receive, you may file a grievance in writing or by phone to the

Grievance & Appeals Department, at the following address: Blue Cross of California, BH Grievance and Appeals, PO Box 23330, San Diego,

CA 92193, Fax: (805) 384-3171, Phone: (800) 365-0609, or online at: www.bluecrossca.com/youreap. We are required to inform you of the

following:

California Department of Managed Health Care (DMHC)

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (800) 365-0609 and use your health plan's grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. I have reviewed and understand the information listed above.

Client Name:

 

 

Client Signature: _____________________________ Date: ___________

 

 

(Please Print)

Social Security #

___ ___ ___ -___ ___ - ___ ___ ___ Company Name: _________________________________________

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

EAP Freedom of Choice Information

Your employer-paid EAP counseling sessions have been completed. You and the provider have discussed the nature of your problem(s) and the Provider has recommended additional behavioral health services. The Provider and you should have reviewed all of the alternatives for continuing services including factors of geography, provider specialization, financial arrangements, and insurance coverage. Having carefully considered all of these options, it is important that you understand you are exercising free choice if you decide to continue treatment with your EAP provider. With your decision, the responsibility for payment will transfer to you and/or your health plan.

EAP is not responsible for payment of services beyond the number of sessions allowed under your EAP benefit.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

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1. The eap services rendered anthem form needs particular information to be typed in. Ensure that the subsequent fields are completed:

Completing section 1 of eap services rendered

2. After filling in the previous section, go on to the next step and fill in the essential particulars in these fields - Scheduled Appt Date Date Reported, Start Date, Company, Sessions Provided, End Date, EAP Model, Date Date, Provider Signature Date, Mail Claims to EAP Claims, Granite Ridge Drive th Floor, Or Fax to, San Diego CA, For Claim Status Option, IMPORTANT WARNING This message is, and Confidential Health Information.

Sessions Provided, For Claim Status   Option, and End Date inside eap services rendered

People generally make errors when completing Sessions Provided in this part. Ensure that you reread whatever you type in here.

3. This next section will be focused on Confidential Health Information, Client Name EAP Assessment Check, Alcohol, Drug, Impacted By Alcohol, Impacted by Drug Family, EmotionalPsychological, Reference Required, Company, MaritalCouple Problem, Violence, Medical Problem, Legal, Financial Problem, and Impacted by EmotionalPsych of - complete each of these blanks.

Part number 3 of filling in eap services rendered

4. To go ahead, this next step will require typing in several empty form fields. These include Benefit Utilization, EAP Assistance Only Referrals, Referrals Not Utilizing Insurance, Referral Information The Client, Psychiatrist, Psychologist, MFTLCSW, Community Resources Referrals Not, PCPMedical Specialist, Other, Case Closed EAP Assistance OnlyNo, If care was transferred to another, Phone, Fax, and ReportLetter, which are integral to going forward with this document.

eap services rendered conclusion process explained (step 4)

5. To finish your document, the particular subsection involves a couple of extra fields. Typing in GRIEVANCE PROCEDURE If you are, Client Signature Date, Please Print, Social Security, Company Name, and Anthem Blue Cross is the trade should conclude the process and you're going to be done quickly!

Social Security, GRIEVANCE PROCEDURE If you are, and Please Print inside eap services rendered

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