www.MercyCareAZ.org
December 8, 2021
Billing Requirement Change for IC, 77 and 05 Provider Types

Applicable To: Mercy Care Complete Care, Mercy Care DD, Mercy Care DCS CHP, Mercy Care Long Term Care and Mercy Care RBHA 

Effective for dates of service on or after 3/1/22, AHCCCS has changed their billing requirements regarding IC, 77 and 05 Provider Types.

In order to retain information related to the actual professional practitioner (provider) participating in/performing services associated with clinic visits reported with the IC, 77 or 05 provider type as the service/rendering provider, that professional practitioner (provider) participating in/performing services must also be reported on all claims. Please review the following for additional detail:

CMS Form 1500 (Paper/Web Claim): Field 19 - Additional Claim Information

AHCCCS Fee For Service Manual: Exhibit 10-1 Participating Provider Information - Provider Types IC, 77 and 05. Examples on how to bill are included.

Please don't hesitate to contact your Mercy Care Network Management representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care website.

Thanks for all you do!


www.MercyCareAZ.org