Fillable Form 236: Arizona Service List Service Description ID (Arizona Health Care Cost Containment System)

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Form 236: Arizona Service List Service Description ID (Arizona Health Care Cost Containment System)

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U.S.A. forms for Arizona Health Care Cost Containment System

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Arizona Service List
Write your Santrax ID above for easy reference
English toll-free numbers. Please refer to your Call Reference Guide for additional languages.
Service
ID
Description
Service
ID
Description
102
Home Health, Qualified Physical Therapist 235
Respite Care, Fifteen minute units; Six or
more patients served
104
Home Health, Qualified Occupational
Therapist
236
Respite Care, Fifteen-minute units;
Spouse – limit to 160 units per week
106
Home Health, Qualified Speech-language
Pathologist
237
Respite Care, Fifteen minute units; Family
member or non-spouse not residing at
home
110
Home Health, Registered Nurse 238
Respite Care, Fifteen minute units; Family
member or non-spouse residing in
member’s home
111
Home Health, Registered nurse; Two
patients served
239
Respite Care, Fifteen-minute units;
Agency with Choice
112
Home Health, Registered Nurse; Three
patients served
240
Respite Care, per diem
120
Home Health, Licensed Practical Nurse 241
Respite Care, per diem; Two patients
served
121
Home Health, Licensed Practical Nurse;
Two patients served
242
Respite Care, per diem; Three patients
served
122
Home Health, Licensed Practical Nurse;
Three patients served
243
Respite Care, per diem; Four patients
served
130
Skills Training and Development 244
Respite Care, per diem; Five patients
served
131
Skills Training and Development; Via
interactive audio and video
telecommunication systems
245
Respite Care, per diem; Six or more
patients served
132
Skills Training and Development; Via
interactive audio and video
telecommunication systems; Group
setting
246
Respite Care, per diem; Spouse – limit to
160 units per week
133
Skills Training and Development; Via
interactive audio and video
telecommunication systems; Group
setting; Court-ordered
247
Respite Care, per diem; Family member or
non-spouse not residing at home
134
Skills Training and Development; Group
setting
248
Respite Care, per diem; Family member or
non-spouse residing at home
135
Skills Training and Development; Group
setting; Court-ordered
249
Respite Care, per diem; Agency with
Choice
136
Skills Training and Development; Court-
ordered
250
Private Duty Nursing, Registered Nurse
210
Attendant Care 251
Private Duty Nursing, Registered Nurse;
Two patients served
Arizona Service List
Write your Santrax ID above for easy reference
English toll-free numbers. Please refer to your Call Reference Guide for additional languages.
Service
ID
Description
Service
ID
Description
211
Attendant Care; Two patients served 252
Private Duty Nursing, Licensed Practical
Nurse; Three patients served
212
Attendant Care; Three patients served 260
Private Duty Nursing, Licensed Practical
Nurse
213
Attendant Care; Unskilled Self-directed
care
261
Private Duty Nursing, Licensed Practical
Nurse; Two patients served
214
Attendant Care; Spouse – limit to 160
units per week
262
Private Duty nursing, Licensed Practical
Nurse; Three patients served
215
Attendant Care; Family member or non-
spouse not residing at home
266
Speech therapy, in the home, per diem
216
Attendant Care; Family member or non-
spouse residing in member’s home
270
Occupational therapy, in the home, per
diem
217
Attendant Care; Skilled Self-directed care 280
Physical therapy; in the home, per diem
218
Attendant Care; Agency with Choice 310
Personal Care Services
220
Homemaker Services 311
Personal Care Services; Agency with
Choice
221
Homemaker Services; Agency with Choice 314
Services performed by a home health aide
or certified nurse assistant, per visit
224
Companion Care, adult per 15 minutes 316
Habilitation, residential, waiver; per diem
230
Respite Care, Fifteen-minute units 320
Residential Habilitation
231
Respite Care, Fifteen-minute units; Group
setting
322
Residential Habilitation; Three patients
served
232
Respite Care, Fifteen minute units; Two
patients served
323
Residential Habilitation; Two patients
served
233
Respite Care, Fifteen minute units; Three
patients served
321
Residential Habilitation; Agency with
Choice
234
Respite Care, Fifteen minute units; Four
patients served
325
Home Health respiratory therapy, nos,
per diem
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Form 236: Arizona Service List Service Description ID (Arizona Health Care Cost Containment System)

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Completed 23 May 2022

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