Welcome to the Claims Submission Page

• Member Claim Information for Out-of-Network Providers
• Out of network provider requirements:
• The provider must be fully licensed.
• Your plan must have out-of-network benefits.
• Complete page one and either attach a super bill from the provider or ask the provider to fill out page two.
• Payments can either be sent directly to the member or to the provider, depending on the provider's preference. Leave box 13 blank to receive payment.
• Call the CBHA claims department at 1-800-475-7900 Monday–Friday from 8:30 a.m.–5:00 p.m. for assistance in filling out the form.