For Participating Entity(s)

Carelon Behavioral Health is the Third-Party Administrator for the California Statewide CYBHI Fee Schedule Program​

There are four health insurance plan types that are obligated to reimburse for services CYBHI Fee Schedule program: Medi-Cal Managed Care Plans, Medi-Cal Fee-for-Service, commercial health plans, or disability insurance. Health plans that are regulated by Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) are obligated to reimburse for services billed under the CYBHI Fee Schedule program. There are 43 total health plans across the four categories that are obligated, and state law (Health and Safety Code 1374.722) prohibits health plans and insurers from passing any of the cost of these services on to families.​

Carelon will provide claims administration by:​

• Validating claims and codes received from providers​
• Filing clean claims with the applicable payer​
• Reconciling payer received claims payments to fund providers​
• Data management and security​

Participating Entity – INTERIM Model: Resources & Information

• Interim Model Workflow (vsdx) – Coming SOON!
• Interim Model Memorandum of Understanding (MOU) (pdf)

Claim Invoice/Report

• Claim Invoice File Layout (xlsx) – Coming SOON!
• Claim Invoice File Sample – Pipe Delimited (csv) – Coming SOON!
• Participating Entity(s) Claim Detail Response Guide (pdf)

Secure File Transfer Protocol (SFTP)

• SFTP Workflow (vsdx) – Coming SOON!
• SFTP Template Guide (pdf) – Coming SOON!
• SFTP Template (xlsx) – Coming SOON!

Finance Information

Participating Entity(s) will be required to provide:

• A W-9; and,
• A primary finance Point-of-Contact (Name & Email)

These can be shared with the Plan-to-Plan representative or email to CBH-TPA@carelon.com.

• FAQs (pdf) – Coming SOON!

Participating Entity – ASO Model: Resources & Information

• Coming SOON!