Select the appropriate claim form (refer to table below).
|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:
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
P. O. Box 52089
Phoenix, AZ 85072-2089
|Through Electronic Clearing House|
|Dental||Mercy Care Plan
Dental Claims Department
P. O. Box 61235
Phoenix, AZ 85082-1235
|Not available at this time|
|Family Planning Services||Schaller Anderson, L.L.C., an Aetna Company
P.O. Box 60785
Phoenix, AZ 85082-0785
|Not available at this time.|
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.
Providers must submit the following information:
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.
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:
When filing resubmissions or reconsiderations, please include the following information:
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.
4350 E. Cotton Center Blvd.,
Bldg D, Phoenix,
Mercy Care Plan Member Services
7 a.m. to 6 p.m. Monday-Friday
Mercy Care Advantage Member Services
24 hours a day, 7 days a week
Select the Mercy Care Advantage option
If you or a family member has a medical emergency, dial 911.