Find the form you need for:
Claims
Network Advantage
Generally, claims will be submitted by your network provider. However, if you use a non-network provider, you will need to submit the claim.
You have the following option(s) for submitting claims for services received from non-network providers: using our online tool or mailing a claim.
File an out-of-network claim for behavioral health services online (requires login)
Note regarding medical claims:
If you have questions or concerns regarding a medical claim, please refer to the phone number on your insurance card.
Requesting support and services
Request a search for childcare options - Let us look for anything from all day childcare to after-school programs.
Request a search for eldercare options - Whether they need a little help or full-time care, let us assist in finding care for the elder in your life.
Request a search for convenience service options - We can help you find resources for anything from hobbies, recreation, home repair, travel, and more.
Request a search for parenting support groups, classes and more - Prenatal classes, postpartum support, parenting classes for any parent and parenting situation.
Request a search for educational opportunities - We can help find education resources for pre-school through high school and beyond (college, certification programs, distance learning, etc.).
Requesting support and services
Excuse for Absence
At times, employees may find that their mental health is impairing their ability to work. The Excuse for Absence process allows an employee to request that a licensed therapist assess their current situation and determine whether the employee may be temporarily excused from work. Engaging in this process does NOT guarantee that the clinician will recommend a SEAP Excuse for Absence.
An EFA does not replace or supersede the employer’s administration of its leave policies & procedures. It does not determine whether or not the employee will be paid while they are away.
Questions about workplace polices should be directed to the/your SEAP Coordinator.
- To be eligible, the employee must first call into the State Employee Assistance Program (SEAP) (800.692.7459) to discuss care and next steps. SEAP is available 24/7.
- SEAP can assist employees in identifying an in-network, licensed provider to complete the assessment and offer their recommendations. The employee is required to be in ongoing care with a licensed clinician throughout the duration of time off.
- The employee is expected to follow workplace call-out procedures for the duration of the EFA.
- When ready to return, SEAP must receive advance notification from the clinician recommending a specific Return to Work date.
Please provide this document to the treating clinician. The PEBTF Employee will complete the release of information and the rest of the form must be filled out by the treating clinician. Then both forms will be sent, by the clinician, to the SEAP Management Consultants with/at Optum via email: SEAP@optum.com or by fax at 866.340.5325. No information should be sent to the workplace.
For any questions, please call SEAP 24/7 at 800.692.7459
Note this is only for employees with PEBTF – this should not be used for any other employer/company nor does this apply to family members of PEBTF employees.
Managing your health
Confidential Exchange of Information - Use this form to give permission for your behavioral health provider to contact your medical doctor. This is important because you may be getting medicines from both your behavioral health clinician and your medical doctor. Sometimes medicines don't work well if mixed together. Your doctors need to know about other medicines that you are taking. It is critical to your overall health that your behavioral health provider knows about any medical problems you may have. Contact with your medical doctor ensures you get the best and safest treatment.
Managing Your Healthcare Information - The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. The forms on the following page will help you manage your healthcare information.
Wellness Assessment - Complete this brief pre-visit questionnaire about your emotions and feelings. Take and review it with your clinician to help get services to best meet your needs. Use this form to evaluate your child's emotions and feelings.
Appointment of Representative - A Commercial member (or “patient”) may use this form to designate an authorized representative to act on his or her behalf regarding a grievance, or an appeal of a denial of service or payment.