Integrated Health Homes/Behavioral Health Homes (IHH/BHH)
HCIC Single Case Agreement Request Form Instructions
WHEN TO COMPLETE THE FORM
The Single Case Agreement Request Form should be completed when you are arranging for your client to be seen by a provider that is not part of HCIC’s Fee for Service Provider Network. The form can also be used to add or extend services to existing single case agreements and to request one to one services. Single case agreements are renewed on October 1 of each year. Please contact HCIC’s Medical Management Department for any services requiring prior authorization because of the level of care (Level I or ECT).
INFORMATION REGARDING CONTRACTED PROVIDERS
Please refer to HCIC’s Provider Network Directory for contracted providers. This directory is sent out electronically to our Integrated Health Homes/Behavioral Health Homes. If the provider is not included in the directory, check the Single Case Provider List. In-Network Prescribers need to be utilized for out-of-area placements.
HOW TO COMPLETE THE FORM
Contact the provider to determine exactly what service codes and provider numbers they will be using, and obtain the information below. If the provider does not have an AHCCCS Provider Number, please call HCIC’s Contract Unit for additional information. We cannot contract with any provider who does not have a verified National Provider Identifier (NPI) and current AHCCCS Provider ID number.
IHH/BHH Information: / Your organization’s name and the date of the requestRequester’s name and phone #
Indicate the type of request:
· If this is a referral for a single member, check Single Case Agreement. If you wish HCIC to add new services or locations to an existing SCA check the second box. Check the box for One to One Services if this is the service needed.
Note the client name and ID
Single Case Provider Information: / Provider’s Name and Site address
AHCCCS Provider ID and National Provider ID numbers
Contact Name and Phone # of SCA staff
Indicate if the placement is out of state
Dates you wish the SCA to cover
Indicate if a local prescriber will be needed for Medication Management
Indicate the need/reason for the out-of-network placement
Services to be Provided: / Indicate the type of services being requested. See the Covered Behavioral Health Services Guide for reference.
IHH/BHH Authorized Signature: / Each IHH/BHH Agency should establish who is authorized to sign the Single Case Agreement Request Form.
WHERE TO SEND THE FORM
FAX the request form to HCIC’s Contract Unit at 1-855-408-3400. We will call the provider and negotiate the terms and conditions of the contract and enter the contract information into the contracts and claims payment system. Once the contract is finalized, you will be notified based on the contract information you supplied.
QUESTIONS
Contact HCIC’s Provider Contract Unit at (928) 774-7128 or e-mail Bobbie Wilkes, HCIC’s Contract Manager at or Terilyn Clayton, HCIC’s Provider Contract Specialist at
FAILURE TO COMPLETE THE FORM CORRECTLY WILL RESULT IN THE SINGLE CASE AGREEMENT REQUEST BEING RETURNED TO YOU
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