How to File a Claim

1. Select the appropriate claim form (refer to table below).

   Service	Claim Form
   Medical and professional services	CMS 1500 Form
   • Family planning services – medical	CMS 1500 Form
   • Family planning services – hospital inpatient, outpatient or emergency	CMS UB-04 Form
   • Obstetrical care *Should be billed using Complete Obstetrical Care Package.	CMS 1500 Form*
   Hospital inpatient, outpatient, skilled nursing and emergency room services	CMS UB-04 Form
   General dental services	ADA 2002 Claim Form
   Dental services that are considered medical services (oral surgery, anesthesiology)	CMS 1500 Form

   Instructions on how to fill out the claim forms can be found at the following AHCCCS website addresses:

   • CMS 1500 Form
   • CMS UB-04 Form
   • ADA 2002 Claim Form
2. Complete the claim form.
   • a) Claims must be legible and suitable for imaging and/or microfilming for permanent record retention. Complete ALL required fields and include additional documentation when necessary.
   • b) The claim form may be returned unprocessed (unaccepted) if illegible or poor quality copies are submitted or required documentation is missing. This could result in the claim being denied for untimely filing.
3. Submit original copies of claims electronically or through the mail (do NOT fax). To include supporting documentation, such as members’ medical records, clearly label and send to the Claims Department at the correct address.
   • a) Electronic Clearing House
     Providers who are contracted with Mercy Care can use electronic billing software. Electronic billing ensures faster processing and payment of claims, eliminates the cost of sending paper claims, allows tracking of each claim sent and minimizes clerical data entry errors. Additionally, a Level Two report is provided to your vendor, which is the only accepted proof of timely filing for electronic claims.
     • The EDI vendors that Mercy Care Plan uses are as follows:
       • Emdeon
       • SPSI
       • SSI
     • Contact your software vendor directly for further questions about your electronic billing.
     • Contact your Provider Relations representative for more information about electronic billing.

     All electronic submission shall be submitted in compliance with applicable law including HIPAA regulations and Mercy Care policies and procedures.

   • b) Through the mail to the appropriate address:

     Claims	Mail To	Electronic Submission*
     Medical	Mercy Care Plan Claims Department Attention: Resubmissions P. O. Box 52089 Phoenix, AZ 85072-2089	Through Electronic Clearing House
     Dental	Mercy Care Plan Dental Claims Department Attention: Resubmissions P. O. Box 61235 Phoenix, AZ 85082-1235	Not available at this time
     Family Planning Services	Schaller Anderson, L.L.C., an Aetna Company Claims Department Attention: Resubmissions P.O. Box 60785 Phoenix, AZ 85082-0785	Not available at this time.

Instruction for Specific Claims Types

Skilled Nursing Facilities (SNF)
Providers submitting claims for SNFs should use CMS UB-04 Form.

Refer to the Skilled Nursing Facility Guidelines located under the Provider Reference Tool for additional information.

Dental Claims

• Claims for dental services should be submitted on the standard American Dental Association form - ADA 2002 Claim Form.
• Services provided by an anesthesiologist or medically related oral surgery procedure should be submitted on CMS 1500 Form.

Family Planning Claims

• Claims for medical services will only be accepted on CMS 1500 Form.
• Inpatient hospitalizations, outpatient surgery and emergency department facility claims should be filed on CMS UB-04 Form.
• See the Covered Family Planning Billed Codes under the Provider Reference Tool for additional billing information.

Providers must submit the following information:

• AHCCCS Provider ID number.
• Family planning service diagnosis (all claims must have).
• Explanation of Benefits from other insurance (including Medicare).
• Correctly signed and dated sterilization consent forms.
• The 30-day waiting period can be waived for emergent or medically indicated reasons.
• Operative reports for surgical procedures.
• Use HCPCS "J" codes, and provide the drug administered, NDC code and the dosage for injected substances.
• Payment for IUDs requires a copy of the invoice to establish cost to the provider.
• Anesthesia claims require an ASA code for surgery with the appropriate time reflected in minutes.
• For Family Planning Services Extension Program members, X-ray and lab charges will be paid only if they are related to family planning. There must be a Family Planning Service diagnosis.
• A separate claim must be submitted for each date of service.

Members may request services, such as infertility evaluations and abortions, from providers, whether or not they are registered with AHCCCS, but must sign a release form stating that they understand the service is not covered and that the member is responsible for payment of these services.

If you have authorization or claims questions related to family planning, please call:
Schaller Anderson, an Aetna Company
(602) 798-2745: Phoenix
(888) 836-8147: Outside Phoenix

Complete Obstetrical Care Package
Providers are expected to bill for obstetrical care using the appropriate global packages and file claims using CMS 1500 Form.

How to Submit a Resubmission

Providers have 12 months from the date of service to request a resubmission or reconsideration of a claim. A request for review or reconsideration of a claim does not constitute a claim dispute.

Providers may resubmit a claim that:

• Was originally denied because of missing documentation, incorrect coding, etc.
• Was incorrectly paid or denied because of processing errors

When filing resubmissions or reconsiderations, please include the following information:

• Use the Resubmission Form located under the Provider Reference Tool.
• An updated copy of the claim. All lines must be rebilled or a copy of the original claim (reprint or copy is acceptable) provided.
• A copy of the remittance advice on which the claim was denied or incorrectly paid.
• Any additional documentation required.
• A brief note describing requested correction.
• Clearly label as "Resubmission" or "Reconsideration" at the top of the claim in black ink and mail to appropriate claims address as indicated in address table above.

Resubmissions and reconsiderations may not be submitted electronically. Failure to mail and accurately label the resubmission or reconsideration to the correct address will cause the claim to deny as a duplicate.

Additional information regarding claim submissions can be found in the Provider Manual under Chapter 16 – Billing, Encounters and Claims.