Frequently Asked Questions

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Business Questions and Claims

Covered Services and Prior Authorization

Long Term Care Services

Business Questions and Claims

• Where do providers send a claim?

  Mercy Care Plan Claims Department
  P. O. Box 52089
  Phoenix, AZ 85072-2089

• Where can providers check claim status or claim remit status?

  Visit MercyOneSource. Here you can check the status of claims, remits, prior authorization, verify member eligibility and more.

• How do providers obtain a current Provider Manual or Directory?

  The Find A Provider section of our website is the most current version of our directory. Use it to make referrals to specialists, home health providers and more.

  The Mercy Care Provider Manual is continually updated. The most current version is online.

• How do I find out who my provider representative is?

  Mercy Care assigns every network provider a representative. Provider representatives are in regular contact with providers and/or office staff. You can confirm the name and phone number of your representative by doing a quick online search.

• Are providers able to bill under the mother's ID number for newborns?

  No, newborns will be assigned their own identification numbers, and claims will need to be billed with the newborn's AHCCCS identification number.

• What if the member has insurance other than Medicare? Which fee is used: MCP’s, Medicare’s, or the other insurance?

  Whichever one is the lowest.

• What should I do if it looks like the primary insurance carrier will not be reimbursing me within the 180-day Mercy Care filing limit?

  If you believe you will not be paid by the primary carrier within the 180-day Mercy Care filing limit, you may submit a claim to Mercy Care at the same time you submit a claim to the primary carrier. We will deny the initial claim for lack of an Explanation of Benefits (EOB). This allows you up to 12 months* from the date of service to receive payment from the primary payer and resubmit the claim for reconsideration.

  *Mercy Care may reconsider payment of claims that have been denied for untimely filing in situations when the provider was making an effort to determine the extent of liability.

• Is an authorization number necessary from Mercy Care if the member has other insurance?

  In most cases, no authorization would be required if Mercy Care is the secondary payer. However, if the service is a covered benefit by Mercy Care, but is not a covered benefit by the primary payer, then an authorization would be required, if the service is listed as a service that requires a prior authorization by Mercy Care.

• Are providers able to bill bilateral procedures on one line or two?

  Mercy Care follows the same billing procedure as CMS and AHCCCS in regard to bilateral procedures. Providers are to bill bilateral procedures not inherently bilateral on one claim line with a “50” modifier (bilateral service) and one unit on the line.

  Example 1: CPT 69210 is for removal of impacted cerumen, one or both ears. CPT 69210 is inherently bilateral, therefore the code should be submitted on one line only with units = 1.

  Example 2: CPT code 29830 is for a diagnostic arthroscopy of the elbow. CPT 29830 is not inherently bilateral, therefore, if this procedure was performed on both the left and right elbows, the code should be submitted on one line with one unit. Modifier 50 should be appended to the code to indicate it was a bilateral procedure.

• With multiple modifiers are the providers to bill with a "99"? How should providers bill with multiple modifiers?

  If there are multiple modifiers on a single line, they should bill the modifiers together (i.e. 5159, please do not place a space between the modifiers).

• Can CMS 1500 claims be submitted with date spans?

  MCP does not accept CMS 1500 claims submitted with date spans. Exception: Date spans may be billed if the dates of service are consecutive. Example: DOS 7/1/09-7/2/09; 99233; 2 units

• How should hospitals bill for outpatient late charges?

  The entire claim should be re-billed with the late charges included and clearly marked as a resubmission. MCP will reverse the original claim and repay the new claim to include the late charges to avoid duplicate denials.

• How should providers submit claims for new drugs on the market?

  The provider should submit the claim using the appropriate HCPCS code including a copy of the drug invoice that includes the NDC number, drug name, and the cost of the drug.

• If a member requests a change in their primary care provider, when will the change be effective?

  If a member requests a change in their primary care provider, the change to the requested primary care physician becomes effective the first day of the following month.

• If a member is referred to a specialist and MCP is the second party to be billed, to submit a claim, does a provider need to receive a referral or obtain a prior authorization to submit the secondary claim to MCP?

  If the primary carrier accepts a claim with or without a prior authorization or a referral, MCP will coordinate services and reimburse accordingly. However, if the service is known to not be covered by the primary insurance carrier and is covered by Mercy Care, an authorization should be obtained from Mercy Care.

Covered Services and Prior Authorization

• How do providers obtain authorizations from Mercy Care?

  Mercy Care requires prior authorization for selected acute outpatient services and planned hospital admissions. Prior authorization is not required for emergency services. Learn what services require prior authorization.

  To request a prior authorization:

  1. Verify member eligibility prior to the provision of services.
  2. Fully complete appropriate referral/authorization form and attach supporting documentation.
  3. Submit request via fax, MercyOneSource or telephone.

  Fax numbers:
  Outpatient Requests and Elective Surgeries: (602) 659-1655 or (800) 217-9345
  Inpatient Hospital: (602) 659-1963 or (866) 300-3926
  Pharmacy: (800) 854-7614

  Questions about covered services, the status of a referral or the need for authorization should be directed to the Prior Authorization Department.

• How do providers verify enrollment of a member?

  You can verify a member’s eligibility at MercyOneSource.

• What services are covered under Mercy Care?

  You can learn more specifics about covered services online.

• If a non-contracted primary care physician refers to a contracted specialist, can the specialist see the member and receive payment?

  The contracted specialist will be reimbursed for services provided as along as the specialist is contracted and appropriate authorization of services is obtained.

• Is the meningitis vaccine covered for members over the age of 18?

  Yes, meningitis vaccine is covered.

• Do lab tests sent to contracted hospitals require prior authorization?

  No, laboratory tests may be sent to contracted hospitals for processing. Mercy Care encourages providers to send these lab tests to the plan-contracted clinical laboratory.

• Which cardiac testing procedures require prior authorization?

  The following cardiac testing requires prior authorization:

  • Intracardiac electrophysiological procedures
  • Echocardiography (No PA required when in specialist’s office)
  • Cardiac catheterizations
  • Angiographic procedures
  • Cardiac stent procedures

• Do allergy injections given in the PCP's office as ordered by an allergist require prior authorization?

  Allergy injections given in an allergist's office for members over the age of 21 require authorization.

• When requesting authorization for elective hospital admissions, is the provider required to submit the "end" date of the admission?

  No, the provider only needs to submit the date of the surgery (the beginning date of the admission).

• Are there behavioral health benefits for Mercy Care Plan members? If so, who provides the behavioral health services?

  1. If a member is enrolled in Mercy Care Plan’s Acute Care or DD programs, there are behavioral health benefits available to the member. The Regional Behavioral Health Authority (RBHA) delivers behavioral health (mental health and substance abuse) services to these members.
  2. If a member is enrolled in Mercy Care Plan’s Long Term Care program, there are behavioral health benefits available to the member. These services are provided by Mercy Care Plan when authorized by the member’s case manager.
  3. If a member is enrolled in Mercy Care Advantage programs, Mercy Care Advantage covers these services under certain conditions.
  4. Mercy Healthcare Group (MHG) members do not have behavioral health benefits through MHG.

• Does MCP have a specific Behavioral Health release of information form?

  Behavioral health providers may utilize their own release of information form.

Long Term Care Department

• Do all Long Term Care members have case managers?

  Yes, all Long Term Care members are assigned a case manager. Case managers are assigned based on the ZIP code in which the member lives. If you are looking for a member’s case manager, call Member Services.

• What services are authorized by a case manager?

  All home- and community-based services, including attendant care, housekeeping, home health, respite, home-delivered meals and outpatient behavioral health services, are authorized by the case manager. In addition, skilled nursing home placement and assisted living placements are also authorized. If you are not sure if a service requires prior authorization or can be authorized by the assigned case manager, visit Prior Authorization.

• If a member requests additional services or more hours than I have been authorized to provide, whom should I contact?

  If a member is requesting additional services beyond those that have been authorized, the member should be told to contact his or her case manager.