AZ Mercy Care Outpatient Behavioral Health Non-Par Provider Initial Single Case Agreement Request Form 2016-2025 free printable template
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This document is used to request authorization for outpatient behavioral health services from a non-participating provider. It includes member information, clinical team details, and justification
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How to fill out AZ Mercy Care Outpatient Behavioral Health
How to fill out AZ Mercy Care Outpatient Behavioral Health Non-Par
01
Gather necessary personal information such as your name, address, and contact details.
02
Obtain the AZ Mercy Care Outpatient Behavioral Health Non-Par application form from the appropriate website or office.
03
Fill out the application form with accurate information, ensuring that all required fields are completed.
04
Provide details about your mental health history and any current treatments or medications.
05
If applicable, include information about your insurance coverage or payment options.
06
Review the form for any errors or missing information.
07
Submit the completed form as directed, either online or via mail, and keep a copy for your records.
Who needs AZ Mercy Care Outpatient Behavioral Health Non-Par?
01
Individuals experiencing mental health issues who require outpatient behavioral health services.
02
People seeking services without being tied to a specific in-network provider.
03
Patients needing flexible treatment options from external providers.
04
Families looking for mental health support for their members.
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What is AZ Mercy Care Outpatient Behavioral Health Non-Par?
AZ Mercy Care Outpatient Behavioral Health Non-Par refers to a specific outpatient behavioral health service network in Arizona that operates outside of traditional provider networks, offering mental health and substance use disorder services.
Who is required to file AZ Mercy Care Outpatient Behavioral Health Non-Par?
Providers who deliver outpatient behavioral health services that do not have contracts with Mercy Care in Arizona are required to file the AZ Mercy Care Outpatient Behavioral Health Non-Par.
How to fill out AZ Mercy Care Outpatient Behavioral Health Non-Par?
To fill out the AZ Mercy Care Outpatient Behavioral Health Non-Par form, providers need to enter their billing information, patient details, services provided, and relevant treatment codes according to the guidelines established by Mercy Care.
What is the purpose of AZ Mercy Care Outpatient Behavioral Health Non-Par?
The purpose of AZ Mercy Care Outpatient Behavioral Health Non-Par is to ensure that all necessary outpatient behavioral health services provided by non-contracted providers are documented and reimbursed by Mercy Care.
What information must be reported on AZ Mercy Care Outpatient Behavioral Health Non-Par?
The information that must be reported includes the provider's details, patient information, date of service, type of service rendered, diagnosis codes, and any relevant modifiers for billing purposes.
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