Request for Electronic Claim Submission Form

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    REQUEST FOR ELECTRONIC CLAIM SUBMISSION


    Elena Kaiser Psychotherapy LCPC ATR BC is a member of the Blue Cross Blue Shield of Illinois (BCBS-IL) Participating Provider Organization.
    If you would like Elena Kaiser Psychotherapy LCPC ATR BC to submit your claims electronically, please review the information below, and return it to Elena Kaiser

  • INSURANCE CLAIM SUBMISSION POLICY

    • Clients are responsible for contacting their insurance companies and understanding their insurance prior to the first session.
    • Charges for services not covered by insurance, e.g., deductibles, uncovered and ineligible services, and all charges for services provided over the maximum allowable benefit for the year, are the client’s responsibility.

  • Clients who change insurance companies or become eligible for Medicare while in therapy at Elena Kaiser Psychotherapy LCPC ATR BC must immediately notify Elena Kaiser.
    • A change in insurance while in therapy may mean:
    1. Clients may no longer be able to collect from insurance if they wish to keep the same therapist, or if they must be reimbursed by insurance, OR 2. Clients may have to refer to a different therapist other than Elena Kaiser

  • POLICY ON PRE-AUTHORIZATIONS

    Some BCBS plans may use third-party administrators to pre-authorize their mental health benefits. Please contact BCBS at the beginning of your treatment to determine if pre-authorization is needed prior to treatment.

    • Please work directly with Elena Kaiser to make sure that all authorizations are acquired at the appropriate times in order to maximize your benefits.
    • If services are performed without authorization, all uncovered services or services covered at a lower rater will be the client’s responsibility.

  • POLICY ON 3RD PARTY COVERAGE

    Some BCBS plans may use third-party administrators to pre-authorize their mental health benefits. Please contact BCBS at the beginning of your treatment to determine if pre-authorization is needed prior to treatment.

    • Please be aware that if your mental health benefits are covered through another carrier, such as United Behavioral Health, Magellan, ComPsych, or Value Options, Elena Kaiser Psychotherapy LCPC ATR BC is not considered in network and PPO rates do not apply.
    • Outsourced coverage cannot be submitted electronically, and you will be expected pay the full fee at the time of service.

  • Insurance Information

    PLEASE FILL IN ALL APPLICABLE FIELDS AND SUBMIT TO YOUR ELENA KAISER WITH A COPY OF YOUR INSURANCE CARD FRONT & BACK

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  • I have reviewed and I understand Elena Kaiser Psychotherapy LCPC ATR BC Insurance Submission Policy and request to have my claims filed electronically with Blue Cross Blue Shield of IL.

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