Find the form you need for:
Claims
Network Advantage
Generally, claims will be submitted by your network provider. However, if you use a non-network provider, you will need to submit the claim.
You have the following option(s) for submitting claims for services received from non-network providers: using our online tool or mailing a claim.
File an out-of-network claim for behavioral health services online (requires login)
Mail completed claims forms to:
Claims Processing
P.O. Box 30755
Salt Lake City, UT 84130-0755
For fastest service, please fax completed claims forms to: 248-733-6085
You can also mail forms to:
Claims Processing
P.O. Box 30755
Salt Lake City, UT 84130-0755
Mail completed claims forms to:
FMH
P.O. Box 25946
Overland Park, KS 66225
Mail completed claims forms to:
Claims Processing
P.O. Box 30602
Salt Lake City, UT 84130-0602
Mail completed claims forms to:
Claims Processing
P.O. Box 30760
Salt Lake City, UT 84130-0760
Mail completed claims forms to:
UnitedHealthcare
P.O. Box 5220
Kingston, NY 12402-5220
Mail completed claims forms to:
Oldsmar Service Center
P.O. Box 740800
Atlanta, GA 30374-0800
Mail completed claims forms to:
USBHPC / Partnership Health Plan Claims
P.O. Box 88013
San Diego, CA 92168
Mail completed claims forms to:
Claims Processing
P.O. Box 30757
Salt Lake City, UT 84130-0757
Foreign Claim Filing:
The following applies to U.S. benefits-eligible employees who access MHSA services while traveling abroad. When outside the U.S., mental health and substance abuse providers and treatment facilities are out-of-network and no authorization is required for treatment. Bills from these providers will be processed by Optum at the in-network coverage level, with any applicable copayments applied.
Download, print and complete claim form
- Fax form(s) to 1-248-733-6085 ATTN: Hewlett Packard Enterprises Employee Claims
- Be sure to include the following (in English or accompanied by an English translation):
- Employee name and Social Security number or Alternate ID
- Original receipts
- Patient's name and date of birth
- Date and description of service(s) provided
- Unit cost of service (per hour or per day charge, for example)
- Total cost of service(s)
- CPT or diagnostic codes are not required
Bills will be paid in U.S. dollars. If the bill is submitted in a foreign currency, it will be converted and paid in U.S. dollars based on the exchange rate on the date of service and checks will be mailed to the employee (not to the provider) at the address provided on the claim form, or the mailing address in the claims processing system.
In almost all cases where claims are incurred outside of the U.S., the provider will require full payment at the time of service.
Claim Filing and Timing
Be sure to keep copies of all bills and claims for your records. Once your claim is processed, OptumHealth will send you an explanation of benefits and a check for the amount covered under your plan.
All claims must be submitted within 18 months of the date services were received.
How to contact Optum
To contact Optum, please call 855-892-2392. Customer service representatives are available from 8 a.m. to 5 p.m., Pacific Time.
Foreign Claim Filing:
The following applies to U.S. benefits-eligible employees who access MHSA services while traveling abroad. When outside the U.S., mental health and substance abuse providers and treatment facilities are out-of-network and no authorization is required for treatment. Bills from these providers will be processed by Optum at the in-network coverage level, with any applicable copayments applied.
Download, print and complete claim form
- Fax form(s) to 1-248-733-6085 ATTN: HP Inc. Employee Claims
- Be sure to include the following (in English or accompanied by an English translation):
- Employee name and Social Security number or Alternate ID
- Original receipts
- Patient's name and date of birth
- Date and description of service(s) provided
- Unit cost of service (per hour or per day charge, for example)
- Total cost of service(s)
- CPT or diagnostic codes are not required
Bills will be paid in U.S. dollars. If the bill is submitted in a foreign currency, it will be converted and paid in U.S. dollars based on the exchange rate on the date of service and checks will be mailed to the employee (not to the provider) at the address provided on the claim form, or the mailing address in the claims processing system.
In almost all cases where claims are incurred outside of the U.S., the provider will require full payment at the time of service.
Claim Filing and Timing
Be sure to keep copies of all bills and claims for your records. Once your claim is processed, OptumHealth will send you an explanation of benefits and a check for the amount covered under your plan.
All claims must be submitted within 18 months of the date services were received.
How to contact Optum
To contact Optum, please call 855-892-2392. Customer service representatives are available from 8 a.m. to 5 p.m., Pacific Time.
Other forms
Note regarding medical claims:
If you have questions or concerns regarding a medical claim, please refer to the phone number on your insurance card.
Requesting support and services
Request a search for childcare options - Let us look for anything from all day childcare to after-school programs.
Request a search for eldercare options - Whether they need a little help or full-time care, let us assist in finding care for the elder in your life.
Request a search for convenience service options - We can help you find resources for anything from hobbies, recreation, home repair, travel, and more.
Request a search for parenting support groups, classes and more - Prenatal classes, postpartum support, parenting classes for any parent and parenting situation.
Request a search for educational opportunities - We can help find education resources for pre-school through high school and beyond (college, certification programs, distance learning, etc.).
Requesting support and services
Excuse for Absence
At times, employees may find that their mental health is impairing their ability to work. The Excuse for Absence process allows an employee to request that a licensed therapist assess their current situation and determine whether the employee may be temporarily excused from work. Engaging in this process does NOT guarantee that the clinician will recommend a SEAP Excuse for Absence.
An EFA does not replace or supersede the employer’s administration of its leave policies & procedures. It does not determine whether or not the employee will be paid while they are away.
Questions about workplace polices should be directed to the/your SEAP Coordinator.
- To be eligible, the employee must first call into the State Employee Assistance Program (SEAP) (800.692.7459) to discuss care and next steps. SEAP is available 24/7.
- SEAP can assist employees in identifying an in-network, licensed provider to complete the assessment and offer their recommendations. The employee is required to be in ongoing care with a licensed clinician throughout the duration of time off.
- The employee is expected to follow workplace call-out procedures for the duration of the EFA.
- When ready to return, SEAP must receive advance notification from the clinician recommending a specific Return to Work date.
Please provide this document to the treating clinician. The PEBTF Employee will complete the release of information and the rest of the form must be filled out by the treating clinician. Then both forms will be sent, by the clinician, to the SEAP Management Consultants with/at Optum via email: SEAP@optum.com or by fax at 866.340.5325. No information should be sent to the workplace.
For any questions, please call SEAP 24/7 at 800.692.7459
Note this is only for employees with PEBTF – this should not be used for any other employer/company nor does this apply to family members of PEBTF employees.
Managing your health
Confidential Exchange of Information - Use this form to give permission for your behavioral health provider to contact your medical doctor. This is important because you may be getting medicines from both your behavioral health clinician and your medical doctor. Sometimes medicines don't work well if mixed together. Your doctors need to know about other medicines that you are taking. It is critical to your overall health that your behavioral health provider knows about any medical problems you may have. Contact with your medical doctor ensures you get the best and safest treatment.
Managing Your Healthcare Information - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. The forms on the following page will help you manage your healthcare information.
Managing Your Healthcare Information - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. The forms on the following page will help you manage your healthcare information.
Release of Information - Member must complete the release of information form, include all necessary documentation and sign before information will be sent to a third party (i.e. physician’s office or insurance company) or discussed with an individual that you designate.
Submit online Release of Information form
Download Release of Information form
Download Revocation of Release of Information form
Fax: 844-386-9286
Mail: UnitedHealthcare Community & State, PO Box 30753, Salt Lake City, UT 84130
Release of Information - Member must download, print and complete the release of information form, include all necessary documentation and sign before information will be sent to a third party (i.e. another clinician, physician’s office or insurance company) or discussed with an individual that you designate. Please consult with and Employee Assistance professional on where to mail or fax.
Wellness Assessment - Complete this brief pre-visit questionanaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs. Use this form to evaluate your child's emotions and feelings.
EAP Wellness Assessment (Adult) - Complete this brief pre-visit questionanaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs. Use this form to evaluate your child's emotions and feelings.
Grievance form - Use this form if you would like to file an EAP or Behavioral Health related complaint. If you would like to file an appeal, please call the number on the back of your insurance card.
GRIEVANCE FORM - Use this form if you would like to file a complaint or appeal. You may also file a complaint or appeal by calling the number on the back of your card.
Appointment of Representative - A Commercial member (or “patient”) may use this form to designate an authorized representative to act on his or her behalf regarding a grievance, or an appeal of a denial of service or payment.
Appointment of Representative - A Medicare, Medicaid or dually funded Medicare and Medicaid member (or “patient”) may use this form to designate an authorized representative to act on his or her behalf in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeals process. Be sure to include the member’s name, date of birth, address information and subscriber ID that we have within our systems. This information is required for identification and authentication purposes. This information can be added on a cover sheet if you are unable to legibly add on this form.
Medical Plan Assistance Program - The Medical Plan Assistance Program (MPAP) provides free or reduced-cost medical coverage to benefits-eligible caregivers who are eligible based on family size and income.