EAP Patient Submission Blue Cross (Anthem) EAP Submission Provider name Provider Email Patient Name Patient URL (Copy the web address from internet browser) Patient Authorization # Did you send to a copy of the authorization form to MCMSouth? Yes No Assessment Check 1 box only Alcohol Drug Impacted by Alcohol Family/ Significant Other Impacted by Drug Family/ Significant Other Emothional/ Psychological Impacted by Emotional/ Pysch of Family/ Significant Other Eating Disorder Family Problems Marital/ Couple Problem Violence Medical Problem Legal Financial Problem Work Related Concern Dependent Care Other Issues Anthem Blue Cross required information (check 1 box only) Recommendation: (Primary) Check 1 box only EAP only Medical Doctor referral Psychiatric meds Eval/tx Alcohol/ drug detoxification Inpatient alcohol/ drug tx Structured outpatient alcohol/ drug tx Non-Hospital Residential Facility Inpatient Psychiatric tx If your patient is using Blue Cross (Anthem) Please complete this section Utilization: Check 1 box only EAP Assistance only Referrals Not Utilizing Insurance Benefits (Community Resources) Referrals Utilizing Insurance Benefits If your patient is using Blue Cross (Anthem) Please complete this section Referral Information. The Client was referred to: Check 1 box only Psychatrist Psychologist MFT/ LCSW Community Resources (Referrals not Utilizing Insurance Benefits) PCP/ Medical Specialist Other Case Closed (EAP Assistance Only/ No Additional Referral Needed) If your patient is using Blue Cross (Anthem) Please complete this section If care 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 If your patient is using Blue Cross (Anthem) Please complete this section Dispostion of Case: Resolved Improved No Change Deteroited Declined Recommendation Unable to Contact If your patient is using Blue Cross (Anthem) Please complete this section Sessions Date(s) (Please list if not shown in software) The EAP sessions to be billed Is this the last EAP session for patient? Yes No Share this:TweetShare on TumblrPocketPrintWhatsAppMoreReddit
