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  WTC Centers of Excellence
  Mental Health Resources
  9/11-Related Mental Health Conditions
     
  By the NYC Health Commissioner
     
  9/11-Affected People
  Healthcare Professionals
  Researchers
     



 

 

Submitting Claims

Please remember that claims must be received by March 31, 2011 for services provided from January 2, 2007 through January 7, 2011.

The following information will help you file claims for the NYC 9/11 Benefit Program for Mental Health & Substance Use Services.

If you have private insurance, you must use your insurance coverage before accessing the NYC 9/11 Benefit Program.

Send claims to:

QualCare, Inc.
P.O. Box 1269
Piscataway, NJ 08855-1269

For claims or billing questions, call QualCare at (866) 885-2895.

For questions about your enrollment status, contact or insurance information changes, covered fees or services, call your Benefit Coordinator at 917-438-9779.

Covered Services:

  • Outpatient mental health and substance use services: The benefit program covers out-of-pocket costs for outpatient treatment. There is no dollar cap on reimbursement for members of Group A PDF Document (Reader Required; Click to Download). For members of Group B PDF Document (Reader Required; Click to Download), reimbursement is limited to $3,000 over the lifetime of the benefit.
  • Medication and laboratory work related to mental health and substance use treatment: In addition, the benefit covers reimbursement for medication and/or laboratory work up to $1,500 over the lifetime of the benefit.
  • Psychological evaluations and testing: The benefit covers up to eight hours of evaluation and testing for children age 21 and under.

The benefit program does not cover the following:

  • Inpatient services
  • Emergency room visits and related services
  • Acupuncture
  • Art therapy services and other expressive therapies
  • Missed appointments
  • Medication not related to mental health or substance use
  • Services provided outside New York State

Treatment Providers

The NYC 9/11 Benefit Program provides reimbursement only for services that are delivered by providers who are licensed/certified in New York State, or who work under the supervision of a New York State-licensed provider in the same field of practice, and practice in New York State.

Services delivered by the following licensed or certified professionals are covered under the NYC 9/11 Benefit Program:

  • Physicians
  • Psychologists
  • Social workers
  • Nurse practitioners
  • Certified alcoholism and/or substance abuse counselors
  • Mental health counselors
  • Marriage and family counselors
  • Licensed psychoanalysts (state license holders only; national certification is not sufficient)

Proof of licensure, such as a copy of the active license, is required before payment can be made. Providers who do not meet these requirements may receive reimbursement only if they are under the direct supervision of a provider who does meet these requirements.

The NYC 9/11 Benefit Program recommends that enrollees work with their existing insurance to find a provider. The program will cover out-of-pocket costs, such as co-payments and deductibles.

Claim Submission Deadline

All claims must be received by March 31, 2011 for services provided between January 2, 2007 to January 7, 2011.

 

Claims for services received before you were enrolled in the program, but after January 2, 2007:

Must be submitted within one year from the date you enroll in the Program

Claims for services received after you enrolled in the Program:

Must be submitted within one year from the date of service

Claims Instructions for Mental Health and Substance Use Treatment

Please remember to make a copy of all claims for your records before mailing to QualCare (address provided above). All claims PDF Document (Reader Required; Click to Download) must include the following information:

Patient Information

  • First & last name
  • Address (city, state, zip code)
  • Date of birth
  • Program identification number
  • Gender
  • Name of health insurance plan

Provider Information

  • Name of provider
  • Office address (city, state, zip code)
  • Phone number
  • License type and number, state issuing license, and expiration date
  • Tax ID number or social security number
  • Provider's account number

 

Service Information

  • Each date of service
  • Billed amount (per date of service)
  • Code and type(s) of service for each date (HCPCS or CPT codes)
  • Treating diagnosis/diagnosis code (ICD or DSM IV)
  • Place of service

If you have insurance:

You or your provider must bill your insurance first and then submit the following documents to QualCare:

  • A copy of the Explanation of Benefits (EOB) from your insurance company. This statement typically comes from your insurance company and shows what portion of the claim was already paid.
  • A completed Claim Payment Request Form   PDF Document (Reader Required; Click to Download). The Claim Payment Request Form must be signed by your provider.

 

Claims will not be processed without a claim payment request form PDF Document (Reader Required; Click to Download) and an EOB.

If you are uninsured or your insurance does not cover mental health or substance use treatment:

You or your provider must submit the following documents to QualCare:

  • A completed Claim Payment Request Form PDF Document (Reader Required; Click to Download) signed by your provider.
  • A receipt from your provider's office for the payment for which you are seeking reimbursement.

Claims Instructions for Laboratory Services

Most laboratories will submit claims to QualCare on your behalf. If this is not the case, you or your laboratory must complete the Claim Payment Request Form PDF Document (Reader Required; Click to Download) and attach a laboratory services bill that includes the following information:

  • Name of the lab
  • Date of service
  • Procedure code
  • Charges
  • Diagnosis 

Claims Instructions for Prescription Medications

When submitting claims for prescription medication, complete questions one through seven on the claim form, and attach receipts from your pharmacy or mail order supplier.  

The receipts must list:

  • Medication name
  • Out-of-pocket expenses for the medication (such as your co-payment or deductible).

Pharmacy printouts that list patient name, date filled, type of prescriptions and expenses also are acceptable.

If you have insurance, you must use your insurance benefit first. Most pharmacies accept insurance and will charge you for a portion of the prescription cost, as allowed by your insurance plan.

Payments for prescription medication can only be issued directly to you. Payments cannot be made directly to pharmacies for prescription services.

Receipt of Payments

Payments for outpatient treatment will be made to you unless you indicate on the claim form that you would like payment made directly to the provider. If you have health insurance, claims must first be sent to your insurance company.

Payments for medication are reimbursements only, so all payments are made to you after the purchase is made.

There is no actual or implied contract between treatment providers and the NYC 9/11 Benefit Program. Reconciliation of payment is between the patient and the provider.

Provider Information


 
 

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