Forms, guides, and resources

Find all the forms, guides, tools, and other resources you need to support the day-to-day needs of your patients and office.^*

Billing and claims

95-Day Waiver Request Form

120-Day Waiver Request Form

150-Day Waiver Request Medicaid Only

365-Day Waiver Form

2019 Psychology and Neuropsychology Testing and Evaluation Service Codes FAQ

Adjustment Void Request Form

Claim Inquiry Form

CMS 1500 Claim Form

Inpatient Treatment Report Instructions

Medicare Waiver of Liability Form

Payment Integrity Provider Documentation Standards and Requirements

Psychological Neuropsychological Testing Update

Third-Party Liability Indicator

Tips for Completing a CMS 1500

Tips for Completing the UB04

Change request

Change of Address Packet

Disclosure of Ownership Form

Facility Address Change Form

Facility Initial Application

Facility Recred Application

Facility Roster Form

Group Addition Form

Group Practice Roster

Group Practice Tip Sheet

Leave of Absence Out of Office Notification Form

Locations and Services Form

Roster for ABA Paraprofessional Providers

Site Information Change Form

Clinical

ABA Authorization Request Form 2019 CPT Codes

ABA Treatment Report Guidelines

Coordination of Care Authorization

Esketamine-Spravato Request Form

ECT Authorization Request Form

Inpatient Treatment Report

Member Coordination of Care Tip Sheet

Outpatient Medication Management Registration Form

Outpatient Treatment Report Form

Psych Neuropsych Evaluation Request Form

Reporting a Potential Quality of Care Concern Provider Form

rTMS Authorization Request Form

Treatment Record Review Audit Tool

Employee Assistance Program (EAP)

Authorization to Disclose Health Information for Formal or Mandatory Referrals to the EAP

Authorization to Disclose Health Information for Formal or Mandatory Referrals to the EAP (Spanish)

Authorization to Disclose Health Information

CAF-1 EAP Case Activity and Billing Form

CAF-2 EAP Case Activity and Billing Form

EAP Case Activity and Billing Form FAQ

EAP Participant Statement of Understanding

EAP Participant Statement of Understanding (Spanish)

EAP Provider FAQ

EAP Provider Handbook

EAP Statement of Understanding - Formal or Mandatory Referrals

EAP Statement of Understanding - Formal or Mandatory Referrals (Spanish)

Important EAP Case Activity and Billing Form Information

270 271 Companion Guide

837 Health Care Claim Companion Guides

Claims resources

UniCare’s electronic Payer ID is 80314. For information about electronic transaction documents for UniCare claims, code sets, electronic remittance advice (ERA) registration, and more, please visit UniCare’s Filing Electronic Claims.

Important documentation

Massachusetts Medical Necessity Criteria

Policy and Procedure Manual

Provider Support Tools Video

UniCare Provider Tip Sheet

Contact information

Customer service:
Credentialing and contracting
844-265-7592
Monday to Friday, 8 a.m. to 6 p.m. Eastern time

Provider relations:
Credentialing and contracting
844-265-7592
Monday to Friday, 8 a.m. to 6 p.m. Eastern time
provider.relations@carelonbehavioralhealth.com

UniCare e-Solutions:
Claims questions
800-470-9630
Monday to Friday, 11 a.m.- to7:30 p.m. Eastern time
e-solutions.support@unicare.com

Electronic data interchange (EDI) Helpdesk:
ProviderConnect technical questions
888-247-9311
Monday to Friday, 8 a.m. to 6 p.m. Eastern time

State-specific resources:

Questions? We're here to help.

Whether you have a question or are interested in learning more about how we can best support you, please call our National Provider Services Line at 800-397-1630, Monday to Friday, 8 a.m. to 8 p.m. Eastern time.

Questions? We're here to help.

Whether you have questions or are interested in learning more about how we can best support you, please reach us by calling our National Provider Services Line at 800-397-1630, Monday through Friday, 8 a.m. to 8 p.m. Eastern time.

* Today we are Carelon Behavioral Health, but when some of these materials were developed, we were Beacon Health Options.