Get the free Mercy Care Plan Remit Format for EFT Form

If you have any questions Please contact the Claims Department at (602) 263-3000 or (800) 624-3879 Mercy Care Plan 4350 E. Cotton Center Blvd. Building D Phoenix, AZ 85020 Remit Date: Beginning Balance:

How to fill out mercy care plan remit

How to fill out a Mercy Care plan remit:

1. Obtain the remit form from Mercy Care or download it from their website.
2. Fill in the basic information section, including your name, address, and contact details.
3. Provide the necessary patient information, including the patient's name, date of birth, and insurance details.
4. Indicate the services or treatments provided to the patient by listing the respective procedure codes, dates, and charges.
5. If applicable, include any supporting documentation or medical records that may be required for reimbursement.
6. Calculate the total charges for the services rendered and enter the amount in the designated field.
7. Verify that all the information provided is accurate and complete.
8. Sign the remit form and date it.
9. Keep a copy of the completed remit form for your records.
10. Submit the remit form to Mercy Care according to their instructions.

Who needs a Mercy Care plan remit:

1. Healthcare providers who have provided services to patients covered under Mercy Care.
2. Individuals seeking reimbursement for medical services received while covered under Mercy Care insurance.
3. Medical facilities or organizations that have contracted with Mercy Care for providing healthcare services to their members.

For pdfFiller’s FAQs

What is mercy care plan remit?

Mercy Care Plan remit is a form used to report and submit payment for services provided to Medicaid patients.

Who is required to file mercy care plan remit?

Healthcare providers who have provided services to Medicaid patients through Mercy Care Plan are required to file remit.

How to fill out mercy care plan remit?

Mercy Care Plan remit can be filled out electronically or manually using the required fields to report services provided and payment details.

What is the purpose of mercy care plan remit?

The purpose of Mercy Care Plan remit is to ensure healthcare providers are properly reimbursed for services provided to Medicaid patients.

What information must be reported on mercy care plan remit?

Information such as patient details, services provided, dates of service, and payment amount must be reported on Mercy Care Plan remit.

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