"Reimbursement Form - Community Health Education Reimbursement Program (Cherp)" - New Hampshire

Reimbursement Form - Community Health Education Reimbursement Program (Cherp) is a legal document that was released by the New Hampshire Department of Administrative Services - a government authority operating within New Hampshire.

Form Details:

  • Released on October 1, 2020;
  • The latest edition currently provided by the New Hampshire Department of Administrative Services;
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State of New Hampshire
Community Health Education
Reimbursement Form
Important
Please read and follow the instructions located on the front and back of this form. Complete all unshaded areas of the form electronically or by printing clearly
with a non‑erasable ink pen. This form will be returned to you if it is not complete. Anthem Blue Cross and Blue Shield (Anthem) will send reimbursement to the
subscriber when approved. Please expect 6‑8 weeks to process once Anthem receives this form.
Member information
Last name
First name
M.I.
1
Date of birth (MMDDYYYY)
Member identification number as shown on your ID card — Please include the 3-letter prefix.
Sex
2
3
4
Male
Female
Group (employer) name
Group no. (located on your ID card)
5
State of New Hampshire
Subscriber information
Last name
First name
M.I.
6
Street address
City
State ZIP code
Phone number
7
Check box if this is a new address.
Participating vendor information
Vendor name
Participating vendor ID no. (please affix sticker)
9
83-9999999-NH-01
8
Street address
City
State ZIP code
DO NOT WRITE IN SHADED AREAS
Date of class (MMDDYYYY)
Place of service
10
11
99
From:
To:
Class name
Diagnosis code
Amount paid by member
Total number of sessions
12
13
14
15
$
R69
Instructor/class leader name
Check box if member completed the program
16
(allowed to miss only one session per series)
17 Type of class — Check only one category
17 Type of class — Check only one category
18 Procedure code
18 Procedure code
S9453
S9451
Smoking cessation
Physical activity
S9452
S9442
Nutrition education
Childbirth education
S9449
S9444
Weight management
Parenting education
S9454
S9444
Stress management
CPR/First aid
Authorizations/signatures
We authorize the release to Anthem of any information necessary to process this request for reimbursement. We agree to the information written above,
19
and verify that the member completed the program.
Participating vendor signature
Date (MMDDYYYY)
X
20 I authorize the release to Anthem of any information necessary to process this request for reimbursement. I agree to the information written above and
verify that I completed the program.
Member signature
Date (MMDDYYYY)
X
The persons signing this form are advised that the willful entry of false or fraudulent information renders you liable to be withdrawn from this Community Health
Education program.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc.
Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
55101NHMENABS Rev. 10/20
1 of 2
3630302 55101NHMENABS SONH Comm Health Ed Reimburse Prt FR 10 20
State of New Hampshire
Community Health Education
Reimbursement Form
Important
Please read and follow the instructions located on the front and back of this form. Complete all unshaded areas of the form electronically or by printing clearly
with a non‑erasable ink pen. This form will be returned to you if it is not complete. Anthem Blue Cross and Blue Shield (Anthem) will send reimbursement to the
subscriber when approved. Please expect 6‑8 weeks to process once Anthem receives this form.
Member information
Last name
First name
M.I.
1
Date of birth (MMDDYYYY)
Member identification number as shown on your ID card — Please include the 3-letter prefix.
Sex
2
3
4
Male
Female
Group (employer) name
Group no. (located on your ID card)
5
State of New Hampshire
Subscriber information
Last name
First name
M.I.
6
Street address
City
State ZIP code
Phone number
7
Check box if this is a new address.
Participating vendor information
Vendor name
Participating vendor ID no. (please affix sticker)
9
83-9999999-NH-01
8
Street address
City
State ZIP code
DO NOT WRITE IN SHADED AREAS
Date of class (MMDDYYYY)
Place of service
10
11
99
From:
To:
Class name
Diagnosis code
Amount paid by member
Total number of sessions
12
13
14
15
$
R69
Instructor/class leader name
Check box if member completed the program
16
(allowed to miss only one session per series)
17 Type of class — Check only one category
17 Type of class — Check only one category
18 Procedure code
18 Procedure code
S9453
S9451
Smoking cessation
Physical activity
S9452
S9442
Nutrition education
Childbirth education
S9449
S9444
Weight management
Parenting education
S9454
S9444
Stress management
CPR/First aid
Authorizations/signatures
We authorize the release to Anthem of any information necessary to process this request for reimbursement. We agree to the information written above,
19
and verify that the member completed the program.
Participating vendor signature
Date (MMDDYYYY)
X
20 I authorize the release to Anthem of any information necessary to process this request for reimbursement. I agree to the information written above and
verify that I completed the program.
Member signature
Date (MMDDYYYY)
X
The persons signing this form are advised that the willful entry of false or fraudulent information renders you liable to be withdrawn from this Community Health
Education program.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc.
Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
55101NHMENABS Rev. 10/20
1 of 2
3630302 55101NHMENABS SONH Comm Health Ed Reimburse Prt FR 10 20
Submission instructions
The State of New Hampshire Community Health Education Reimbursement Form needs to be completed by the member attending
the program. Submit only one form per member per program.
Example: John Doe attended Freedom From Smoking 1/1 – 1/28 = one form
John Doe attended How to Begin Exercising 1/15
= one form
Jane Doe attended Freedom From Smoking 1/1 – 1/28 = one form
The participating vendor will:
1. Assist the member in filling out the unshaded sections.
2. Collect the member’s class fee up‑front and record amount paid in section 14.
3. Verify all the information is correct and complete section 16, sign, and date section 19.
4. Have the member sign and date section 20.
5. Submit the completed claim form to the address listed below.
For Yoga, YMCA, American Red Cross and Weight Watchers classes only, the member will:
1. Have the instructor record the amount paid in section 14.
2. Have the instructor complete section 16, sign, and date section 19, to verify class attendance.
3. Verify all the information is correct, sign, and date section 20.
4. Retain a copy if desired (form will not be returned).
5. Submit the completed claim form within 30 days after program completion to the address listed below.
Claims submission address:
Claims Department
Anthem Blue Cross and Blue Shield
P.O. Box 533
North Haven, CT 06473‑0533
Member reimbursement will be denied if:
1. The member was not a current or eligible Anthem member when class was attended, or
2. The member did not complete the program (allowed to miss maximum of one class per series).
This form will be returned if the form is not completed with the required information.
Special note: Because Anthem products vary, members should check with Customer Service to verify their eligibility for this
program. The Customer Service phone number is located on the back of the member’s ID card.
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