NYSHIP Empire Plan, mental health and substance use benefit (Carelon administered as published)

Source: https://www.cs.ny.gov/forms/cms1500-MHSU.pdf

Read date: 10-09-2026

Research steps

1. Use only Mental Health and Substance Use Claim Form CMS-1500 (02-12). Complete every field marked R and every applicable field marked C in the form's completion guide. Mental Health and Substance Use Claim Form
2. The member or authorized person signs box 12. The person rendering care signs box 31 and states the licensure level. Leave box 13 unsigned to keep payment with the member; signing box 13 authorizes direct payment to the provider. Mental Health and Substance Use Claim Form
3. Include an explanation of benefits when Medicare or another plan processes first. Include any supporting information needed for a clean claim. Mental Health and Substance Use Claim Form Empire Plan certificate
4. Open the Carelon Behavioral Health MemberConnect portal linked by the certificate and submit the claim form. Portal upload YES. UNREADABLE: the exact post-login menu, file types, size limit, file count, document grouping, and confirmation. MemberConnect Empire Plan certificate
5. For a nonparticipating provider, file no later than 120 days after the end of the calendar year in which the covered expenses were incurred, or 120 days after Medicare or another plan processes the claim. A documented late-filing exception may apply when timely filing was not reasonably possible. Mental Health and Substance Use Claim Form
6. Check the claim in MemberConnect. Carelon states that a complete retrospective claim determination is made within 30 calendar days. Empire Plan certificate

Filing facts

• Portal upload: YES
• Portal: Carelon Behavioral Health MemberConnect
• Portal path: Open the MemberConnect portal linked by the Empire Plan certificate; exact post-login claim-submission menu is UNREADABLE
• Mail address: Carelon Behavioral Health, P.O. Box 1850, Hicksville, NY 11802
• Fax: NOT PUBLISHED
• Attach: Insured ID; member and insured identity; other coverage; employment or accident indicators; member information-release signature; conditional assignment; referring provider NPI; ICD-CM diagnosis; service dates; place of service; CPT or HCPCS; diagnosis pointer; charges; units; rendering provider ID or NPI when applicable; Federal Tax ID; total charge; amount paid; rendering provider signature and credentials; service facility address; billing provider name, address, ZIP, phone, and NPI
• File types: NOT PUBLISHED
• File size limit: NOT PUBLISHED
• Maximum files: NOT PUBLISHED
• One file or separate files: NOT PUBLISHED
• Confirmation: NOT PUBLISHED
• Status check: MemberConnect > Claims for status; written claim determination
• Processing time: 30 calendar days for a complete retrospective claim
• Member deadline: 120 days after the end of the calendar year in which covered expenses were incurred
• Deadline basis: If Medicare or another plan processes first, 120 days after that processing; late filing may be allowed when timely filing was not reasonably possible and documented
• Mental health route: Carelon Behavioral Health administers the Mental Health and Substance Use Program; MemberConnect is the published claim portal

Confirm the address, fax number or portal path on the insurer's own claims page before you send; read on 10-09-2026.