Chemical Dependency and Mental Health Claims

Chemical Dependency and Mental Health Claims Submission Guidelines

A claim for chemical dependency for mental health benefits should be filed with the Health Fund's chemical dependency and mental health benefit manager, PacifiCare Behavioral Health, following the instructions below:

• Download and print the HCFA-1500 Form (Adobe Acrobat reader required, click here for free download).
• Complete the form in its entirety and submit it along with your provider's bill (including itemized diagnoses and payment sheets) to PacifiCare at following  address:
  
  PacifiCare Behavioral Health
  P.O. Box 31053
  Laguna Hills, CA 92654