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Provider Manual
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Table of Contents
(Last Updated 10/01/2006)
MERCY CARE PLAN COMPLIANCE PROGRAM
TABLE OF CONTENTS
Chapter 1---WELCOME TO MERCY CARE PLAN
Chapter 2---GLOSSARY
Chapter 3---PROVIDER AND SPECIALIST STANDARDS AND RESPONSIBILITIES
Chapter 4---COVERED AND EXCLUDED SERVICES
Chapter 5---MEMBER SERVICES
MEMBER RIGHTS AND RESPONSIBILITIES
MEMBER COPAYS, PREMIUMS, AND DEDUCTIBLES
SAMPLE MEMBER ID CARDS
PROVIDER ASSISTANCE PROGRAM FORM
Chapter 6---PROVIDER SERVICES
Chapter 7---MATERNAL HEALTH/OBSTETRICAL CARE
OBSTETRICAL AUTHORIZATION FORM
AHCCCS CERTIFICATE OF NECESSITY FOR PREGNANCY TERMINATION
Chapter 8---COORDINATION OF FAMILY PLANNING SERVICES
FAMILY PLANNING PRIOR AUTHORIZATION FORM
FAMILY PLANNING BILLING CODES
CERTIFICATE OF PREGNANCY TERMINATION
STERILIZATION CONSENT FORM
Chapter 9---CHILDREN'S HEALTH SERVICES (EPSDT)
EPSDT PERIODICITY SCHEDULE
CHILDHOOD IMMUNIZATION SCHEDULE (EPSDT)
CLAIM CODES FOR EPSDT
VERBAL LEAD SCREENINGS
Chapter 10---DENTAL AND VISION SERVICES
DENTAL PRIOR AUTHORIZATION REQUEST FORM
DENTAL AUTHORIZATION STATUS FORM
Chapter 11---CASE / DISEASE MANAGEMENT
Chapter 12---BEHAVIORAL HEALTH SERVICES
BEHAVIORAL HEALTH REFERRAL FORM
Chapter 13---DIVISION OF DEVELOPMENTAL DISABILITIES (DD LTC)
Chapter 14---INPATIENT CONCURRENT REVIEW
Chapter 15---PRIOR AUTHORIZATION AND REFERRALS
PRIOR AUTHORIZATION REQUIREMENTS
PRIOR AUTHORIZATION REQUEST FORM
PRIOR AUTHORIZATION REQUEST FORM - GYN PROCEDURE
PHARMACY PRIOR AUTHORIZATION REQUEST FORM (Mercy Care Plan)
PHARMACY PRIOR AUTHORIZATION REQUEST FORM (Mercy Care Advantage)
BENEFITS MATRIX
Chapter 16---QUALITY MANAGEMENT
AMBULATORY MEDICAL REVIEW FORM
Chapter 17---PREFERRED DRUG LIST
PREFERRED DRUG LIST (Mercy Care Plan)
COMPREHENSIVE FORMULARY (Mercy Care Advantage)
PHARMACY PRIOR AUTHORIZATION FORM (Mercy Care Plan)
PHARMACY PRIOR AUTHORIZATION FORM (Mercy Care Advantage)
Chapter 18---CLAIMS AND ENCOUNTERS
SAMPLE HCFA 1500 FORM
SAMPLE UB 92 FORM
SAMPLE REMITTANCE ADVICE - CHECK
SAMPLE REMITTANCE ADVICE - EFT
MEDICAID SAMPLE REMITTANCE ADVICE - CHECK
MEDICAID SAMPLE REMITTANCE ADVICE - EFT
Chapter 19---APPEALS AND STATE FAIR HEARINGS
Chapter 20---MERCY HEALTHCARE GROUP
HEALTHSTYLE BENEFIT PLANS COVERED SERVICES
Chapter 21---KIDSCARE PROGRAM
Chapter 22---ARIZONA LONG TERM CARE SERVICES (ALTCS)
Chapter 23---CULTURALLY COMPETENT PATIENT CARE
Chapter 24---MERCY CARE ADVANTAGE
PSYCH TESTING REQUEST FORM
REQUEST FOR BEHAVIORAL HEALTH AUTHORIZATION FORM
October 6, 2008