- US Legal Forms
- Form Library
- More Forms
- More Multi-State Forms
- AZ Mercy Care Outpatient Behavioral Health Non-Par Provider Initial Single Case Agreement Request 2015
Get AZ Mercy Care Outpatient Behavioral Health Non-Par Provider Initial Single Case Agreement Request 2015-2024
This form must be completed and submitted by the provider service agency and clinical team coordinating the member s clinical care. The SCA fax number is 1-860-975-1040. Approval must be provided by the agencies clinical director or designee. The form must be filled out in its entirety. Any gaps, missing or incorrect data will be cause for the request form to be returned and the process will have to be resubmitted. The member s current treatment plan must accompany this request form.
How It Works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
Tips on how to fill out, edit and sign Achievable online
How to edit Measurable: customize forms online
Forget an old-fashioned paper-based way of completing Measurable. Get the document completed and certified in minutes with our top-notch online editor.
Are you forced to edit and complete Measurable? With a professional editor like ours, you can perform this task in only minutes without having to print and scan documents back and forth. We provide completely editable and straightforward document templates that will serve as a starting point and help you complete the necessary form online.
All forms, by default, contain fillable fields you can complete as soon as you open the template. However, if you need to improve the existing content of the document or insert a new one, you can choose from a number of customization and annotation options. Highlight, blackout, and comment on the document; add checkmarks, lines, text boxes, graphics and notes, and comments. Additionally, you can swiftly certify the template with a legally-binding signature. The completed document can be shared with other people, stored, imported to external programs, or transformed into any other format.
You’ll never go wrong by choosing our web-based tool to complete Measurable because it's:
- Effortless to set up and utilize, even for users who haven’t completed the documents online before.
- Robust enough to accommodate multiple editing needs and document types.
- Safe and secure, making your editing experience protected every time.
- Available across various devices, making it effortless to complete the document from everywhere.
- Capable of creating forms based on ready-made templates.
- Compatible with numerous file formats: PDF, DOC, DOCX, PPT and JPEG etc.
Don't spend time completing your Measurable obsolete way - with pen and paper. Use our feature-rich tool instead. It provides you with a comprehensive suite of editing options, built-in eSignature capabilities, and convenience. The thing that makes it differ from similar alternatives is the team collaboration options - you can work together on documents with anyone, build a well-structured document approval workflow from A to Z, and a lot more. Try our online tool and get the best bang for your buck!
Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.
Resubmitted FAQ
-
Mercy Care is a local not-for-profit managed care organization. We provide coverage for people who qualify for Arizona Health Care Cost Containment System (AHCCCS) benefits.
-
Payer Name: Mercy Care Plan (AHCCCS)|Payer ID: 86052|Professional (CMS1500)/Institutional (UB04)[Hospitals]
-
Per your contract, we need to receive claims for services you provide our members in a timely manner: New claims: File claims with a valid claim form within 150 days from the date you performed services or from the date of eligibility posting, whichever is later.
-
Owned by Dignity Health and Ascension Health, Mercy Care has served Medicaid members since 1985. Mercy Care provides access to health care services for families, children, seniors, and people with physical and developmental/cognitive disabilities.
Designee Related content
-
The Romance of Modern Invention, by Archibald...
THE ROMANCE OF MODERN INVENTION. CONTAINING INTERESTING DESCRIPTIONS IN NON-TECHNICAL...
Learn more -
Might Is Right 24-Hour Radio Special
Starting exactly at Midnight EST on Radio Free Satan, a 24 hour broadcast will commense...
Learn more -
Chronology of Events Relating to Rajneeshpuram...
15 to study mental health care said use of medication there was "'very responsible. ... 18...
Learn more -
The Day We Got Guns
Swami Prem Rajesh, dearly loved by family and friends, died 14 May, 2010. The unpublished...
Learn more -
chocolate-history.pdf
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their...
Learn more -
Color Atlas and Text of Dental Care of the Elderly
Jan 24, 2009 — Critical Psychiatry: The Politics of Mental Health (Penguin...
Learn more -
- Future Opioids
Publisher's note: The ideas, procedures, and suggestions contained in this book are not...
Learn more -
Physics with High Energy Colliders|S. Yamada
Jan 24, 2008 — Principles Of Evaluation And Research For Health Care Programs|Karen...
Learn more -
Urgent Care Rancho Bernardo Scripps
Next available: Not available Not available ScheduleLearn More Urgent Care See our first...
Learn more -
SECTION D - PROGRAM REQUIREMENTS
Oct 1, 2015 — conditions that require costly treatment; c. Shall not employ or contract...
Learn more -
Integrating Behavioral and Physical Health for...
by M Au · 2017 · Cited by 3 — SUMMARY: A growing number of states are integrating...
Learn more -
FAA-0001A - Application for Benefits
Use this application to see if you and members of your household qualify for: • Free or...
Learn more -
New Directions Behavioral Health: Home
Access your New Directions Employee Assistance Program (EAP) benefits, information about...
Learn more -
MANAGED CARE AND FEE-FOR-SERVICE
Dec 18, 2009 — In managed care, the MCOs have the flexibility to enter into single-case...
Learn more -
Price Terms in Hospital Admission Agreements
by GA Nation III · 2019 · Cited by 13 — As a result, most contracts signed by or on...
Learn more -
STATE OF MISSOURI HOSPICE MANUAL
11.9.A NON-BILLING MO HEALTHNET PROVIDER. MO HealthNet Managed Care health plan providers...
Learn more -
SSI/SSDI Outreach, Access, and Recovery (SOAR)
Dec 12, 2023 — Become a SOAR Case Manager. SOAR-trained case managers provide...
Learn more -
The Impact of Supportive Housing on the Costs of...
May 1, 2021 — “Housing is Health Care”: The Impact of. Supportive Housing on the...
Learn more -
The Medicare and Medicaid Intersection: Caring for...
by N Super · 2002 — Three plans were awarded contracts in the initial bid in Maricopa...
Learn more -
Color Atlas and Text of Dental Care of the...
Jan 24, 2009 — Critical Psychiatry: The Politics of Mental Health (Penguin...
Learn more -
Physics with High Energy Colliders|S. Yamada
Jan 24, 2008 — Principles Of Evaluation And Research For Health Care Programs|Karen...
Learn more -
Urgent Care Rancho Bernardo Scripps
Next available: Not available Not available ScheduleLearn More Urgent Care See our first...
Learn more -
Color Atlas and Text of Dental Care of the Elderly
Jan 24, 2009 — Critical Psychiatry: The Politics of Mental Health (Penguin...
Learn more -
Physics with High Energy Colliders|S. Yamada
Jan 24, 2008 — Principles Of Evaluation And Research For Health Care Programs|Karen...
Learn more -
Urgent Care Rancho Bernardo Scripps
Next available: Not available Not available ScheduleLearn More Urgent Care See our first...
Learn more -
Mercy Care d/b/a Mercy
Jun 29, 2020 — The purpose of this Agreement is to coordinate care for individuals in...
Learn more -
Member FAQs
The process is completed through Health-e-Arizona Plus (HEAplus). For ALTCS customers...
Learn more -
Provider Manual 04-03-19
Community Plan, Mercy Care Plan, and Care 1st Health Plan Arizona. American Indian Health...
Learn more -
Mercy Care d/b/a Mercy
Jun 29, 2020 — The purpose of this Agreement is to coordinate care for individuals in...
Learn more -
EX-10.19
Offer the provider a single case agreement if the provider is unwilling to ... behavioral...
Learn more -
Prior Authorization Forms
The Initial Dialysis Case Creation Form is the first form that is completed by registered...
Learn more -
2022 Mercy Care Operational Review
The reviewers use a process approved by the Centers for Medicare and Medicaid Services...
Learn more -
Provider Manual 04-03-19
Community Plan, Mercy Care Plan, and Care 1st Health Plan Arizona. American Indian Health...
Learn more -
Behavioral Health & Substance Abuse Services for...
For children in out-of-home care, upon completion of the initial evaluation by the...
Learn more -
49 SECTION F – SERVICE COORDINATION - La Dept...
Health involves securing a single case agreement with an out-of-network provider, and...
Learn more -
EX-10.14
Under this Contract, the Contractor is the single entity that is responsible for...
Learn more -
2022 Mercy Care Operational Review
The reviewers use a process approved by the Centers for Medicare and Medicaid Services...
Learn more -
State Approaches to Integrating Physical and...
by MH Soper — working with One Care plans to expand contracts with behavioral health...
Learn more -
Medical Services for Children in Out-of-Home Care
Initial and Ongoing Health Care Assessment and Services. Gather available information...
Learn more -
74 SECTION H – UTILIZATION MANAGEMENT
Aetna Better Health views each service request as an opportunity to educate providers and...
Learn more -
EX-10.14
Under this Contract, the Contractor is the single entity that is responsible for...
Learn more -
SB1646 - 561R - I Ver
(e) Feasible alternatives and concurrent or additional treatment opportunities for the...
Learn more -
SB1646 - 561R - I Ver
(e) Feasible alternatives and concurrent or additional treatment opportunities for the...
Learn more -
Behavioral Health & Substance Abuse Services for...
For children in out-of-home care, upon completion of the initial evaluation by the...
Learn more -
MercyCare Health Plans
... non-participating providers may be subject to usual and customary charges ... contract...
Learn more -
SECTION D - PROGRAM REQUIREMENTS
Oct 1, 2015 — conditions that require costly treatment; c. Shall not employ or contract...
Learn more -
Integrating Behavioral and Physical Health for...
by M Au · 2017 · Cited by 3 — SUMMARY: A growing number of states are integrating...
Learn more -
Price Terms in Hospital Admission Agreements
by GA Nation III · 2019 · Cited by 13 — As a result, most contracts signed by or on...
Learn more -
The Impact of Supportive Housing on the Costs of...
May 1, 2021 — Behavioral health costs declined 36%, while spending on physical health...
Learn more -
Arizona's Application for a New Section 1115...
Sep 4, 2015 — Instructions: This template is meant to assist states that are developing...
Learn more -
Promising Solutions to our Nation's Behavioral...
The country is facing a behavioral health crisis. Even with the increases in health care...
Learn more -
An Independent Evaluation of the Integrated Care...
individual providers who do not sign a formal contract with the plan but ... health...
Learn more -
Needs Analysis: Current Status, Strategic...
In February of 2014, the Colorado Department of Human Services's (CDHS) Office of...
Learn more -
annals of health law
The Annals of Health Law is proud to present the Fifteenth Issue of our online...
Learn more -
Collective Bargaining Language - Health and Safety...
This page includes sample contract language taken from actual collective bargaining...
Learn more -
SECTION D - PROGRAM REQUIREMENTS
Oct 1, 2015 — conditions that require costly treatment; c. Shall not employ or contract...
Learn more -
Integrating Behavioral and Physical Health for...
by M Au · 2017 · Cited by 3 — SUMMARY: A growing number of states are integrating...
Learn more -
Price Terms in Hospital Admission Agreements
by GA Nation III · 2019 · Cited by 13 — As a result, most contracts signed by or on...
Learn more -
MANAGED CARE AND FEE-FOR-SERVICE
Dec 18, 2009 — In managed care, the MCOs have the flexibility to enter into single-case...
Learn more -
New Directions Behavioral Health: Home
Access your New Directions Employee Assistance Program (EAP) benefits, information about...
Learn more -
Managed Medicaid: Arizona's AHCCCS Experience
by N Super · 2000 — “Managed Medicaid: Arizona's AHCCCS Experience” was the first...
Learn more -
FAA-0001A - Application for Benefits
Use this application to see if you and members of your household qualify for: • Free or...
Learn more -
Office of Inspector General - HHS.gov
Dec 31, 2005 — OIG is dedicated to the mission of detecting fraud, waste, and abuse and...
Learn more -
Emergency Care and Managed Care
by DE Hoffmann · Cited by 29 — Abstract: Managed care plan subscribers in need of...
Learn more -
The Impact of Supportive Housing on the Costs of...
May 1, 2021 — “Housing is Health Care”: The Impact of. Supportive Housing on the...
Learn more -
FY 2015 Provider Network Development and...
Mar 23, 2015 — Mercy Maricopa also holds single case agreements with Rosewood Treatment...
Learn more -
EX-10.14
Under this Contract, the Contractor is the single entity that is responsible for...
Learn more -
Substance Use Disorder Treatment for People With...
Know the process for referring clients for mental illness case management services or for...
Learn more -
Provider Manual 04-03-19
Community Plan, Mercy Care Plan, and Care 1st Health Plan Arizona. American Indian Health...
Learn more -
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT ...
Dec 30, 2019 — Non-Emergency, Out of Network Single Case Agreements. Therapeutic ... The...
Learn more -
Division of Developmental Disabilities Provider...
The Division contracts with Health. Plans to provide all Behavioral Health services...
Learn more -
STANDARD CONTRACT FORM
This form is jointly issued and published by the Office of the Comptroller (CTR), the...
Learn more -
50 State Analysis of Local and Regional Behavioral...
The MHCA assists its members to achieve the goal of community-based treatment which...
Learn more -
Integration of Behavioral and Physical Health...
Mar 2, 2016 — Integrating physical and behavioral health has been shown to reduce...
Learn more -
Summary
million members to AHCCCS Complete Care (ACC) integrated health care plans. By joining...
Learn more -
FY 2015 Provider Network Development and...
Mar 23, 2015 — Mercy Maricopa also holds single case agreements with Rosewood Treatment...
Learn more -
EX-10.19
Offer the provider a single case agreement if the provider is unwilling to ... behavioral...
Learn more -
EX-10.14
Under this Contract, the Contractor is the single entity that is responsible for...
Learn more -
Provider Manual 04-03-19
Community Plan, Mercy Care Plan, and Care 1st Health Plan Arizona. American Indian Health...
Learn more -
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT ...
Dec 30, 2019 — Non-Emergency, Out of Network Single Case Agreements. Therapeutic ... If...
Learn more -
Substance Use Disorder Treatment for People With...
Know the process for referring clients for mental illness case management services or for...
Learn more -
Division of Developmental Disabilities Provider...
The Division contracts with Health. Plans to provide all Behavioral Health services...
Learn more -
Catalog of Medicaid Initiatives Focusing on...
MBHP's new contract to provide managed behavioral health services, care ... Many other...
Learn more -
LA Provider Manual - La Dept. of Health...
... single clinical Case Manager, their caregivers, and their Primary Care Provider...
Learn more -
50 State Analysis of Local and Regional Behavioral...
The MHCA assists its members to achieve the goal of community-based treatment which...
Learn more -
The Romance of Modern Invention, by Archibald...
THE ROMANCE OF MODERN INVENTION. CONTAINING INTERESTING DESCRIPTIONS IN NON-TECHNICAL...
Learn more -
Might Is Right 24-Hour Radio Special
Starting exactly at Midnight EST on Radio Free Satan, a 24 hour broadcast will commense...
Learn more -
Chronology of Events Relating to Rajneeshpuram...
15 to study mental health care said use of medication there was "'very responsible. ... 18...
Learn more -
The Day We Got Guns
Swami Prem Rajesh, dearly loved by family and friends, died 14 May, 2010. The unpublished...
Learn more -
Color Atlas and Text of Dental Care of the Elderly
Jan 24, 2009 — Critical Psychiatry: The Politics of Mental Health (Penguin...
Learn more -
chocolate-history.pdf
Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their...
Learn more -
Physics with High Energy Colliders|S. Yamada
Jan 24, 2008 — Principles Of Evaluation And Research For Health Care Programs|Karen...
Learn more -
- Future Opioids
Publisher's note: The ideas, procedures, and suggestions contained in this book are not...
Learn more -
Urgent Care Rancho Bernardo Scripps
Next available: Not available Not available ScheduleLearn More Urgent Care See our first...
Learn more -
SECTION D - PROGRAM REQUIREMENTS
Oct 1, 2015 — conditions that require costly treatment; c. Shall not employ or contract...
Learn more -
Integrating Behavioral and Physical Health for...
by M Au · 2017 · Cited by 3 — SUMMARY: A growing number of states are integrating...
Learn more -
Price Terms in Hospital Admission Agreements
by GA Nation III · 2019 · Cited by 13 — As a result, most contracts signed by or on...
Learn more -
STATE OF ARIZONA
Mar 23, 2015 — The Consolidated Plan is a document required by the U.S. Department of...
Learn more -
AZ Rural Health Resource Manual 2006.indd
NHSC sites must provide requested health care services regardless of the individual's...
Learn more -
2014-2015 Health Professions Division Catalog
... Health Care Sciences —Occupational Therapy Department. 169. Second Year—Summer...
Learn more -
Arizona's Application for a New Section 1115...
Sep 4, 2015 — Instructions: This template is meant to assist states that are developing...
Learn more -
National Directory of Drug and Alcohols Treatment...
This publication was developed for the Substance Abuse and Mental Health Services...
Learn more -
Patient Protection and Affordable Care Act 111th...
10104) Requires the Secretary to issue regulations for the creation of health care choice...
Learn more -
The Impact of Supportive Housing on the Costs of...
May 1, 2021 — “Housing is Health Care”: The Impact of. Supportive Housing on the...
Learn more
Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.
Keywords relevant to AZ Mercy Care Outpatient Behavioral Health Non-Par Provider Initial Single Case Agreement Request
- aspx
- xxxxx
- maricopa
- 14-day
- HCPCT
- azahcccs
- resubmitted
- designee
- achievable
- observable
- cpt
- insufficiency
- measurable
- reimbursement
- dob
USLegal fulfills industry-leading security and compliance standards.
-
VeriSign secured
#1 Internet-trusted security seal. Ensures that a website is free of malware attacks.
-
Accredited Business
Guarantees that a business meets BBB accreditation standards in the US and Canada.
-
TopTen Reviews
Highest customer reviews on one of the most highly-trusted product review platforms.