• Provider Manual

Provider Manual

CHAPTER 1 – INTRODUCTION TO MERCY CARE

CHAPTER 2 – MERCY CARE PLAN CONTACT INFORMATION

CHAPTER 3 – PROVIDER RELATIONS

CHAPTER 4 – PROVIDER RESPONSIBILITIES

CHAPTER 5 – COVERED AND NON COVERED SERVICES

CHAPTER 6 – EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)

CHAPTER 7 – BEHAVIORAL HEALTH

CHAPTER 8 – FAMILY PLANNING

CHAPTER 9 - MATERNITY

CHAPTER 10 – DENTAL AND VISION SERVICES Dental Services

CHAPTER 11 – CASE MANAGEMENT AND DISEASE MANAGEMENT

CHAPTER 12 – CONCURRENT REVIEW

CHAPTER 13 – PHARMACY MANAGEMENT

CHAPTER 14 – QUALITY MANAGEMENT

CHAPTER 15 – REFERRALS AND AUTHORIZATIONS

CHAPTER 16 – BILLING, ENCOUNTERS AND CLAIMS

CHAPTER 17 – GRIEVANCES, PROVIDER CLAIM DISPUTES AND APPEALS

CHAPTER 18 – FRAUD AND ABUSE

Provider Manual

CHAPTER 1 - INTRODUCTION TO MERCY CARE

1.0 Welcome

Welcome to Southwest Catholic Health Network (SCHN), dba Mercy Care Plan (MCP)! Our ability to provide excellent service to our members is dependent on the quality of our provider network. By joining our network, you are helping us serve those Arizonans who need us most.

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1.1 About SCHN

SCHN, hereafter Mercy Care when referring to all lines of business, is a not-for-profit partnership created in 1985 and sponsored by Catholic Healthcare West and Carondelet Health Network. Mercy Care is committed to promoting and facilitating quality health care services with special concern for the values upheld in Catholic social teaching, and preference for the poor and persons with special needs. Schaller Anderson, an Aetna Company, administers Mercy Care.

Mercy Care has an established, comprehensive model to accommodate service needs within the communities served. This manual contains specific information about MCP to which all Participating Healthcare Professional (PHP)s must adhere. Please refer to Provider Tools on Mercy Care's website for a listing of Forms and Provider Notifications. You can print the MCP Provider Manual from your desktop.

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1.2 Disclaimer

Providers are contractually obligated to adhere to and comply with all terms of the plan and provider contract, including all requirements described in this manual in addition to all federal and state regulations governing the plan and the provider. MCP may or may not specifically communicate such terms in forms other than the contract and this provider manual. While this manual contains basic information about the Arizona Health Care Cost Containment System (AHCCCS), providers are required to fully understand and apply AHCCCS requirements when administering covered services.

Please refer to www.ahcccs.state.az.us for further information on AHCCCS.

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1.3 MCP Overview

MCP is a managed care organization that provides health care services to people in Arizona's Medicaid program. MCP has held a pre-paid capitated contract with the AHCCCS Administration since 1985. MCP provides services to the Arizona Medicaid populations including:

  • Acute Care: Members select the managed care plan to administer their benefits. MCP is contracted in Maricopa, Pima, Graham, Greenlee and Cochise Counties to provide covered services to enrolled members.
  • KidsCare: Healthcare insurance made available by the State of Arizona to offer care at a low cost to Arizona children 18 years old or younger. Effective September 1, 2009 funding for parents of KidsCare has been eliminated and enrollment for children in the KidsCare Program is currently capped. A waiting list is in place for new applicants. KidsCare information is now available on the AHCCCS website and can be reviewed at the following link: Here
    • .
  • Division of Developmental Disabilities Long Term Care program: Members are enrolled through the Arizona Department of Economic Security/Division of Developmental Disabilities (DDD). DDD is a Medicaid program administered by AHCCCS through the Department of Economic Security (DES). MCP is contracted with DDD to provide acute care services.

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1.4 MCP Policies and Procedures

MCP has robust and comprehensive policies and procedures in place throughout its' departments that assure all compliance and regulatory standards are met. Policies and procedures are reviewed on an annual basis and required updates made as needed.

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1.5 Eligibility

The DES, the Social Security Administration or the AHCCCS determines eligibility.

Acute members receive their cards from AHCCCS. DDD members receive an ID card from MCP.

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CHAPTER 2 - MERCY CARE PLAN CONTACT INFORMATION

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2.0 Health Plan Contacts Table
Health Plan Telephone Number Health Plan Web Address
Mercy Care Plan (602) 263-3000
(800) 624-3879 toll-free		 www.MercyCarePlan.com
Mercy Healthcare Group (602) 798-2800
(800) 780-2300 toll-free		 www.MercyHealthcareGroup.com

Express Service Codes

Providers may use "Express Service" Monday through Friday from 8:00 a.m. to 5:00 p.m. To reach a specific service department:

  1. Dial the appropriate Health Plan telephone number
  2. When you hear the automated attendant, use your telephone keypad to enter the corresponding three digit service code.

Mercy Care is available 24 hours a day, seven days a week to assist providers with prior authorization needs.

Service Area Express Service Code
Medical Prior Authorization 622
Pharmacy Prior Authorization 625
Claims 626
Member Eligibility and Verification 629
Transportation non-emergency 630
Provider Relations 631
Health Plan Internal Contact Telephone Number
MCP, MHG DD Representative (602) 453-6026
Claim Disputes Appeals (602) 453-6098
Provider Credentialing (MCP and MHG)
Providers wishing to contract with Mercy Care may fax a letter of interest along with a copy of their W-9 to (860) 975-3201, Attn: Network Development and Contracting. Contract requests will be reviewed and the requesting provider will be notified of contract status. Please note that providers must be board certified or board eligible. To determine the status of a contract request, please call (602) 453-6148.

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2.1 Health Plan Authorization Services Table
Department Services
Medical, Dental or Family Planning Prior Authorization

Prior Authorization Department

Medical or Dental Fax:
(602) 431-7555 (Phoenix)
(800) 217-9345 (Toll Free)

Family Planning Fax:
(602) 431-7303

You may also call our main number and use the express service code listed above.

DES/DDD Prior Authorization: Health Professionals must also obtain prior authorization from the DES/DDD medical director prior to providing sterilization and pregnancy termination procedures for members enrolled with DES/DDD.

Contact Prior Authorization

Inpatient Hospital and Hospice Services

Fax: (602) 431-7363
(866) 300-3926 (Toll Free)

Pharmacy Prior Authorization

Mercy Care Plan and Mercy Healthcare Group
Fax: (800) 854-7614 (Toll Free)

Mercy Care Advantage
Fax: (800) 871-6898 (Toll Free)

Behavioral Health Department
(For Acute and DDD members)

Mercy Care Behavioral Health Coordinator (BHC)

The BHC serves as liaison between members, the Plan and RBHA.

Medical Case Management

Intake Referral
602-453-8391

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2.2 Community Resources Contact Information Table
Community Resource Contact Information
Arizona Early Intervention Program (AzEIP)
Address: 3839 North Third Street, Suite 304
Phoenix, Arizona 85012
Phone: (602) 532-9960, toll free in Arizona (888) 439-5609
Fax: (602) 200-9820
E-mail: allazeip2@azdes.gov
Website: www.azdes.gov
Arizona's Smokers Helpline (Ashline)
Address: P.O. Box 210482
Tucson, AZ 85721
Phone: (800) 55-66-222
Fax: (520) 318-7222
Website: www.ashline.org
Arizona Women, Infants & Children (WIC)
Address: 150 N. 18th Ave. Suite 310
Phoenix, AZ 85007
Phone: (800) 252-5942
(800) 2525-WIC
To report WIC fraud & abuse, call our Fraud Hotline at (866) 229-6561 or E-Mail azwiccomplaints@azdhs.gov
Website: www.azwic.gov
Behavioral Health Services
Address: 150 N. 18th Avenue, #200
Phoenix, AZ 85007
Phone: (602) 364-4558
Fax: (602) 364-4570 Fax
Website: www.azdhs.gov/bhs
Baby Arizona
Address: 801 E. Jefferson
Phoenix, AZ 85034
Phone: (800) 833-4642
Website: www.babyarizona.gov
Community Information and Referral
Address: 2200 N. Central Avenue, Suite 601
Phoenix, AZ 85004
Phone: (602) 263-8856
(800) 352-3792 (area codes 520 & 928)
Website: www.cir.org
Arizona Department of Economic Security - Aging and Adult Services
Phone: (602) 542-4446
Website: www.azdes.gov

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CHAPTER 3 - PROVIDER RELATIONS

3.0 Provider Relations Overview
The Provider Relations department serves as a liaison between MCP and the provider community. They are responsible for training, maintaining and strengthening the provider network in accordance with regulations.

Provider Relations staff conducts onsite provider training, problem identification and resolution, site visits, accessibility audits and develops provider communication materials, including the Provider Manual. They support Network Development and Contracting with multiple functions, including the evaluation of the provider network and compliance, with regulatory network capacity standards.

A Provider Relations representative is assigned to each office. You may reach your representative directly by calling (602) 263-3000 or (800) 624-3879, Express Service Code 631 under Provider Tools to contact the Provider Relations department.

You may also access Provider Relations through the MCP website to electronically verify member eligibility, request prior authorization, review claim status, find a provider, review the Preferred Drug List and find other important information under MercyOneSource. Please refer to section 4.34 MercyOneSource for additional information regarding this.

Contact Provider Relations for:

  • Recent updates
  • Forms
  • Member information
  • Member eligibility
  • To find a participating provider or specialist
  • Prior authorization claim status
  • To review or search the Preferred Drug List
  • Term from practice
  • Notifying the plan of changes to your practice
  • Tax ID change
  • Obtaining a website Login ID
  • Electronic Data Information, Electronic Fund Transfer, Electronic Remittance Advice

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CHAPTER 4 - PROVIDER RESPONSIBILITIES

4.0 Provider Responsibilities Overview

These responsibilities are minimum requirements to comply with contract terms and all applicable laws. Providers are contractually obligated to adhere to and comply with all terms of the plan, provider contract and requirements in this manual. MCP may or may not specifically communicate such terms in forms other than the contract and this manual. This section outlines general provider responsibilities; however, additional responsibilities are included throughout the manual.

Providing Member Care

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4.1 AHCCCS Registration

Each provider must first be registered with AHCCCS and obtain an AHCCCS provider ID number. An active Medicare number must also be attained if providing service for Mercy Care Advantage.

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4.2 Appointment Availability Standards

Providers are required to schedule appointments for eligible members in accordance with the minimum appointment availability standards below. MCP will routinely monitor compliance and seek corrective action plans, such as panel or referral restrictions, from providers that do not meet accessibility standards.

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4.2 - Appointment Availability Standards Table
Provider Type Emergency Services Urgent Care Preventative & Routine Care High Risk Wait Time in Office Standard
PCP Same Day Within 24 hours Within 21 days Less than 45 minutes
Specialty Referrals Within 24 hours Within 3 days of request Within 45 days Less than 45 minutes
Dental Care Within 24 hours Within 3 days of request Within 45 days Less than 45 minutes
Maternity Immediate Second Trimester-within 14 days of request Third Trimester-within 7 days of request Within three days of identification of high risk status Less than 45 minutes
Behavioral Health Within 24 hours Within 30 days of referral or screening Less than 45 minutes
Non Urgent/ Non Emergent Transportation Less than one hour before or after appointment

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4.3 Telephone Accessibility Standards

Providers are responsible to be available during regular business hours and have appropriate after hours coverage. Providers must have coverage 24 hours per day, seven days per week, including on-call coverage. Call coverage does not include referrals to the emergency department.

Examples of after-hours coverage that will result in follow up from MCP:

  • An answering machine that directs the caller to leave a message (unless the machine will then automatically page the provider to retrieve the message).
  • An answering machine that directs the caller to go to the emergency department.
  • An answering machine that has only a message regarding office hours, etc., without directing the caller appropriately, as outlined above.
  • An answering machine that directs the caller to page a beeper number.
  • No answering machine or service.
  • If your answering machine directs callers to a cellular phone, it is not acceptable for charges to be directed to the caller (i.e., members should not receive a telephone bill for contacting their physician in an emergency).
  • Telephones should be answered within five rings and hold time should not exceed five minutes. Callers should not get a busy signal.

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4.4 Covering Physicians

MCP Provider Relations must be notified if a covering provider is not contracted or affiliated with MCP. This notification must occur in advance of providing coverage and MCP must provide authorization. Reimbursement to covering physicians is based on the MCP Fee Schedule. Failure to notify MCP of covering physician affiliations may result in claim denials and the provider may be responsible for reimbursing the covering provider.

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4.5 Verifying Member Eligibility

All providers, regardless of contract status must verify a member's enrollment status prior to the delivery of non-emergent, covered services. A member's assigned provider must also be verified prior to rendering primary care services. MCP will not reimburse providers for services rendered to members that lost eligibility or were not assigned to the primary care provider's panel (unless, s/he is physician covering for a provider).

Member eligibility may be verified through one of the following ways:

  • Website*: www.MercyCarePlan.com. Link available on homepage or you can login to the secure website portal. *You must have a confidential password to access. To register, contact your Provider Relations representative. More information is available in this Provider Manual under section 4.35 MercyOneSource.
  • MediFax: MediFax is an electronic product available through AHCCCS that stores key member information. Use to verify MCP member eligibility for pharmacy, dental, transportation and specialty care.
  • AHCCCS Interactive Voice Response (IVR): To use, dial (602) 417-7200. For providers outside of Maricopa County only please dial 1-800-331-5090.
  • MCP Telephone Verification: Use as a last resort. Call Member Services to verify eligibility at (602) 263-3000 and use Express Service Code 629.. To protect member confidentiality, providers are asked for at least three pieces of identifying information such as member identification number, date of birth and address, before any eligibility information can be released. When calling MCP, use the prompt for the providers.
  • Monthly Roster: Monthly rosters are found on the secure website portal. Contact your Provider Relations representative for more information. Note that rosters are only updated once a month. More information is available in this Provider Manual
    • under section 4.35 MercyOneSource regarding provider rosters.

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4.6 Preventive or Routine Services

Providers are responsible for providing appropriate preventive care for eligible members. Preventive health guidelines are located on the MCP website in the Member Handbook. These preventive services include, but are not limited to:

  • Age-appropriate immunizations, disease risk assessment and age-appropriate physical examinations;
  • EPSDT;
  • Well exams are not covered adults (age 21 and older).

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4.7 Educating Members on their own Health Care

MCP does not restrict or prohibit providers, acting within the lawful scope of their practice, from advising or advocating on behalf of a member who is a patient for:

  • the member's health status, medical care or treatment options, including any alternative treatment that may be self-administered;
  • any information the member needs in order to decide among all relevant treatment options;
  • the risks, benefits, and consequences of treatment or non-treatment; and,
  • The member's right to participate in decisions regarding his or her behavioral health care, including the right to refuse treatment, and to express preferences about future treatment decisions.

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4.8 Emergency Services

Prior authorization is not required for emergency services. In an emergency, members should go to the nearest emergency department.

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4.9 Urgent Care Services

While providers serve as the medical home to members and are required to adhere to the AHCCCS and MCP appointment availability standards, in some cases, it may be necessary to refer members to one of MCP's contracted urgent care centers (after hours in most cases). Please reference Find A Provider on MCP's website and select Urgent Care Facility in the specialty drop down list to view a list of contracted urgent care centers.

MCP reviews urgent care and emergency room utilization for each provider panel. Unusual trends will be shared and may result in increased monitoring of appointment availability.

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4.10 Primary Care Physicians (PCPs)

The primary role and responsibilities of primary care physicians participating in Mercy Care Plan include, but are not be limited to:

  • Providing initial and primary care services to assigned members ;
  • Initiating, supervising, and coordinating referrals for specialty care and inpatient services and maintaining continuity of member care;
  • Maintaining the member's medical record.

The PCP is responsible for rendering, or ensuring the provision of, covered preventive and primary care services to the member. These services will include, at a minimum, the treatment of routine illness, maternity services if applicable, immunizations, Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for eligible members under age 21, adult health screening services and medically necessary treatments for conditions identified in an EPSDT or adult health screening.

PCPs in their care coordination role serve as the referral agent for specialty and referral treatments and services provided to Mercy Care members assigned to them, and attempt to ensure coordinated quality care that is efficient and cost effective. Coordination responsibilities include, but are not limited to:

  • Referring members to providers or hospitals within the Mercy Care Plan network, as appropriate, and if necessary, referring members to out-of-network specialty providers;
  • Coordinating with Mercy Care Plan’s Prior Authorization Department with regard to prior authorization procedures for members;
  • Conducting follow-up (including maintaining records of services provided) for referral services that are rendered to their assigned members by other providers, specialty providers and/or hospitals;
  • Coordinating the medical care of the Mercy Care members assigned to them, including at a minimum:
    • Oversight of drug regimens to prevent negative interactive effects
    • Follow-up for all emergency services
    • Coordination of inpatient care
    • Coordination of services provided on a referral basis, and
    • Assurance that care rendered by specialty providers is appropriate and consistent with each member's health care needs.

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4.11 Specialist Providers

Specialist providers are responsible for providing services in accordance with the accepted community standards of care and practices. Specialists should only provide services to members upon receipt of a written referral form from the member's primary care provider or from another MCP participating specialist. Specialists are required to coordinate with the primary care provider when members need a referral to another specialist. The specialist is responsible for verifying member eligibility prior to providing services.

When a specialist refers the member to a different specialist or provider, then the original specialist must share these records, upon request, with the appropriate provider or specialist. The sharing of the documentation should occur with no cost to the member, other specialists or other providers.

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4.12 Second Opinions

A member may request a second opinion from a provider within the contracted network. The provider should make a recommendation and refer the member to another provider.

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4.13 Provider Assistance Program for Non-Compliant Members

The provider is responsible for providing appropriate services so that members understand their health care needs and are compliant with prescribed treatment plans. Providers should strive to manage members and ensure compliance with treatment plans and with scheduled appointments. If you need assistance helping non compliant members, MCP's Provider Assistance Program is available to you. The purpose of the program is to help coordinate and/or manage the medical care for members at risk. You may complete the Provider Assistance Program Form located on MCP’s website Mercy Care Plan/Provider Tools/Forms and submit it to Member Services for possible intervention.

If you elect to remove the member from your panel rather than continue to serve as the medical home, you must provide the member at least 30 days written notice prior to removal and ask the member to contact Member Services to change their provider. The member will NOT be removed from a provider's panel unless the provider efforts and those of the Health Plan do not result in the member's compliance with medical instructions. If you need more information about the Provider Assistance Program, please contact your Provider Relations representative.

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Documenting Member Care

4.14 Member's Medical Record

The provider serves as the member's "medical home" and is responsible for providing quality health care, coordinating all other medically necessary services and documenting such services in the member's medical record. The member's medical record must be legible, organized in a consistent manner and must remain confidential and accessible to authorized persons only.

All medical records, where applicable and required by regulatory agencies, must be made available electronically.

Each member is entitled to one copy of his or her medical record free of charge.

All providers must adhere to national medical record documentation standards. Below are the minimum medical record documentation and coordination requirements. The following requirements are taken directly from the AHCCCS Medical Policy Manual 940.1:

  • Member identification information on each page of the medical record (i.e., name or AHCCCS identification number)
  • Documentation of identifying demographics including the member's name, address, telephone number, AHCCCS identification number, gender, age, date of birth, marital status, next of kin, and, if applicable, guardian or authorized representative
  • Initial history for the member that includes family medical history, social history and preventive laboratory screenings (the initial history for members under age 21 should also include prenatal care and birth history of the member's mother while pregnant with the member)
  • Past medical history for all members that includes disabilities and any previous illnesses or injuries, smoking, alcohol/substance abuse, allergies and adverse reactions to medications, hospitalizations, surgeries and emergent/urgent care received
  • Immunization records (required for children; recommended for adult members if available)
  • Dental history if available, and current dental needs and/or services
  • Current problem list
  • Current medications
  • Current and complete EPSDT forms (required for all members age 0 through 20 years)
  • Documentation, initialed by the member's PCP, to signify review of:
  • Diagnostic information including:
    • Laboratory tests and screenings
    • Radiology reports
    • Physical examination notes, and
    • Other pertinent data.
  • Reports from referrals, consultations and specialists
  • Emergency/urgent care reports
  • Hospital discharge summaries
  • Behavioral health referrals and services provided, if applicable, including notification of behavioral health providers, if known, when a member's health status changes or new medications are prescribed, and
  • Behavioral health history.
  • Documentation as to whether or not an adult member has completed advance directives and location of the document
  • Documentation related to requests for release of information and subsequent releases, and
  • Documentation that reflects that diagnostic, treatment and disposition information related to a specific member was transmitted to the PCP and other providers, including behavioral health providers, as appropriate to promote continuity of care and quality management of the member's health care.

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4.15 Advance Directives

Providers are required to comply with federal and state law regarding advance directives for adult members. The advance directive must be prominently displayed in the adult member's medical record. Requirements include:

  • Providing written information to adult members regarding each individual's rights under state law to make decisions regarding medical care and any provider written policies concerning advance directives (including any conscientious objections).
  • Documenting in the member's medical record whether or not the adult member has been provided the information and whether an advance directive has been executed.
  • Not discriminating against a member because of his or her decision to execute or not execute an advance directive and not making it a condition for the provision of care.

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4.16 Medical Record Audits

MCP will conduct routine medical record audits to assess compliance with established standards. Medical records may be requested when MCP is responding to an inquiry on behalf of a member or provider, administrative responsibilities or quality of care issues. Providers must respond to these requests promptly. Medical records must be made available to AHCCCS for quality review upon request.

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4.17 Documenting Member Appointments

When scheduling an appointment with a member over the telephone or in person (i.e. when a member appears at your office without an appointment), providers must verify eligibility and document the member's information in the member's medical record.

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4.18 Missed or Cancelled Appointments

Providers must:

  • Document and follow-up on missed or canceled appointments.
  • Notify Member Services by completing a Provider Assistance Program Form located on MCP's website under Mercy Care Plan/Provider Tools/Forms for a member who continually misses appointments.

MCP encourages providers to use a recall system. MCP reserves the right to request documentation supporting follow up with members related to missed appointments.

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4.19 Documenting Referrals

The provider is responsible for initiating, coordinating and documenting referrals to specialists, including dentists and behavioral health specialists within the MCP organization. The provider must follow the respective practices for emergency room care, second opinion and noncompliant members.

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4.20 Respecting Member Rights

MCP is committed to treating members with respect and dignity at all times. Member rights and responsibilities are shared with staff, providers and members each year. Member rights are incorporated herein and may be reviewed in the Member Handbook located in the MCP website.

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4.21 Health Insurance Portability and Accountability Act of 1997 (HIPAA)

The Health Insurance Portability and Accountability Act of 1997 (HIPAA) has many provisions affecting the health care industry, including transaction code sets, privacy and security provisions. HIPAA impacts what is referred to as covered entities; specifically, providers, health plans and health care clearinghouses that transmit health care information electronically. HIPAA has established national standards addressing the security and privacy of health information, as well as standards for electronic health care transactions and national identifiers. All Participating Health Providers (PHP) are required to adhere to HIPAA regulations. For more information about these standards, please visit http://www.hhs.gov/ocr/hipaa/. In accordance with HIPAA guidelines, providers may not interview members about medical or financial issues within hearing range of other patients.

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4.22 Cultural Competency and Health Literacy

Cultural Competency

The Partnership for Clear Health Communication (PCHC) defines health literacy as the ability to read, understand and act on health information. Health literacy relates to listening, speaking, and conceptual knowledge. Health literacy plays an important role in positive patient outcomes. According to PCHC, people with low functional Health Literacy:

  • Have poorer overall health status.
  • Are less likely to adhere to treatment and incur a greater number of medication/treatment errors.
  • Require more health related treatment and care, including 29-69% higher hospitalization rates.
  • Increase higher health care costs - health care costs as high as $7,500 more per annum for a person with limited health literacy.

To increase health literacy, the National Patient Safety Foundation created the Ask Me 3™ program. MCP supports the Ask Me 3™ program, as it is an effective tool designed to improve health communication between patients and providers.

For an Ask Me 3 poster to be displayed in your office, visit: www.npsf.org/askme3.

In accordance with Title VI of the 1964 Civil Rights Act, national standards for culturally and linguistically appropriate health care services and State requirements, MCP is required to ensure that Limited English Proficient (LEP) members have meaningful access to health care services. Because of language differences and inability to speak or understand English, LEP persons are often excluded from programs they are eligible for, experience delays or denials of services or receive care and services based on inaccurate or incomplete information.

Members are to receive covered services without concern about race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information or medical history, ability to pay or ability to speak English. Participating Health Providers (PHP)s are required to treat all members with dignity and respect, in accordance with federal law. Providers must deliver services in a culturally effective manner to all members, including:

  • Those with limited English proficiency (LEP) or reading skills.
  • Those with diverse cultural and ethnic backgrounds.
  • The homeless.
  • Individuals with physical and mental disabilities.

For more detailed information on cultural competence, please refer to the guide entitled Culturally Competent Patient Care: A Guide for Providers and Their Staff, by Georgia Hall, Ph.D. The guide was developed as a cooperative effort on behalf of AHCCCS health plans to assist providers, and is reprinted with the permission of the author.

Health Literacy - Limited English Proficiency (LEP) or Reading Skills

MCP complies with federal and state laws by offering interpreter and translation services, including sign language interpreters, to LEP members. This service affords members access to health care and benefits by providing a range of language assistance services at no cost to the member or provider. MCP strongly recommends the use of professional interpreters, rather than family or friends. Bilingual staff members are available in the member services department to assist LEP members and a TTY line is available for members who are hearing impaired. Further, MCP provides member materials in other formats to meet specific member needs. Providers must also deliver information in a manner that is understood by the member.

To access interpretation services to assist members who speak a language other than English or who use sign language, please call Language Line Services directly at (800) 523-1786. Language Line provides interpreter services in more than 170 languages. This service is available at no cost to you or the member. Additional information regarding Language Line Services can be accessed through the MCP website, under Mercy Care Plan/Provider Tools/Provider Notifications, titled Language Line Quick Reference Guide and Language Line Job Aid.

The PCP is responsible for providing appropriate services so that members understand their health care needs and the member is compliant.

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4.23 Individuals with Disabilities

Title III of the Americans with Disabilities Act (ADA) mandates that public accommodations, such as a physician's office, be accessible to those with disabilities. Under the provisions of the ADA, no qualified individual with a disability may be excluded from participation in or be denied the benefits of services, programs or activities of a public entity, or be subjected to discrimination by any such entity. Provider offices must be accessible to persons with disabilities. Providers must also make efforts to provide appropriate accommodations such as large print materials and easily accessible doorways.

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4.24 Primary Care Physician (PCP) Assignments

MCP automatically assigns members to a provider upon enrollment. Members have the right to change their provider at any time. Member eligibility changes frequently, as a result, providers must verify eligibility prior to delivering services.

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4.25 Plan Changes

MCP members generally are not allowed to change their health plan until their Annual Enrollment Choice (AEC) period, which occurs on the anniversary date of their enrollment. Only in certain circumstances may a member request a change outside of this timeframe. Plan change requests may be granted based on continuity of medical care. Often, these requests involve continuity of prenatal care. The plan change determination will be made by the MCP medical director or designee based on information provided by the PCP.

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Provider Guidelines and Plan Details

4.26 Cost Sharing and Coordination of Benefits

Providers must adhere to all contract and regulatory cost sharing guidelines. When a member has other health insurance such as Medicare, a Medicare HMO or a commercial carrier, MCP will coordinate payment of benefits in accordance with the terms of the PHPs contract and federal and state requirements. AHCCCS registered providers must coordinate benefits for all Mercy Care members in accordance with the terms of their contract and AHCCCS guidelines.

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4.27 Copayments
TMA Copayments

Effective October 1, 2010, Transitional Medical Assistance (TMA) members over the age of 19 will have mandatory copays for some services. The copays are as follows:

Transitional Medical Assistance (TMA) Copay
Service Copay
Office Visit $4.00
All Pharmacy $2.30
Surgeries (In-office, Outpatient, non-emergent, Ambulatory Surgery Centers) $3.00
Out Patient Professional Therapies $3.00

Copays may never be collected for the following services:

  • Emergency services
  • Children under the age of 19
  • Services related to pregnancy or any other medical condition which might complicate pregnancy
  • Family planning services and supplies

If a member is a Qualified Medicare Beneficiary (QMB), the Medicare deductible and coinsurance for eligible Medicare services will continue to be paid.

A provider can enforce collection of these copays and a member can be refused service if the member is not able to pay the copay.

Nominal Copayments
There are also copayment requirements that apply to all other AHCCCS eligible members. These copayments are called "nominal" copayments and are for the following services in the following amounts:

Nominal Copays
  • Service Co-pay
  • Prescription Drugs $2.30
  • Certain Evalualtion & Management Services $3.40
  • Certain Physical, Occupational, or Speech Therapy $2.30

Health care providers may not refuse to provide service if a patient states that they are unable to make these copayments. "Nominal" means that these are non-mandatory copays.

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4.28 Clinical Guidelines

MCP has Clinical Guidelines and treatment protocols available to PHPs to help identify criteria for appropriate and effective use of health care services and consistency in the care provided to members and the general community. These guidelines are not intended to:

  • Supplant the duty of a qualified health professional to provide treatment based on the individual needs of the patient;
  • Constitute procedures for or the practice of medicine by the party distributing the guidelines; or,
  • Guarantee coverage or payment for the type or level of care proposed or provided.

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4.29 Office Administration Changes and Training

Providers are responsible to notify MCP Provider Relations of changes in professional staff at their offices (physicians, physician assistants or nurse practitioners). Administrative changes in office staff may result in the need for additional training. Contact your Provider Services representative to schedule any needed staff training.

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4.30 Contract Additions or Terminations

In order to meet contractual obligations and state and federal regulations, providers must report any terminations or additions to their contract at least 90 days prior to the change. Providers are required to continue providing services to members throughout the termination period. For information on where to send change information, refer to Provider Notice of Change Form under the Mercy Care Plan/Provider Tools/Forms section located on the MCP website.

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4.31 Continuity of Care

Providers terminating their contracts without cause are required to continue to treat MCP members until the treatment course has been completed or care is transitioned. Authorization may be necessary for these services. Members who lose eligibility and continue to have medical needs must be referred to a facility or provider that can provide the needed care at no or low cost. MCP is not responsible for payment of services rendered to members who are not eligible. Please refer to Reference Guide Low Cost/No Cost Health Care Referral List under the Mercy Care Plan/Provider Tools/Provider Notification section if you identify a member in this circumstance. You may also contact MCP’s Case Management Department for assistance.

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4.32 Contract Changes or Updates

Providers must report any changes to demographic information to MCP at least 90 days prior to the change in order to be in compliance with contractual obligations and state and federal regulations. Providers are required to continue providing services to members throughout the termination period. For information on where to send change information, refer to the Table 8, Provider Record Updates (below). Please complete the Provider Notice of Change Form under the Provider Tools/Forms section located on the MCP website.

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4.32 - Provider Record Updates Table
Type of Change Notification Requirements Send to Time to Process
Individual or group name Must mail updated W-9 and letter describing change and effective date Provider Relations 90 days
Tax ID number Must mail updated W-9 and letter describing change and effective date Provider Relations 90 days
Address Must fax (860) 975-3201 or mail Provider Relations 90 days
Staffing changes including physicians leaving the practice Must fax (860) 975-3201 or mail letter describing change and effective date Provider Relations 90 days
Adding new office locations Must fax (860) 975-3034 or mail letter describing change and effective date Provider Relations 90 days
Adding new physicians to current contract Must fax (860) 975-3034 or mail letter describing change and effective date Provider Relations 90 days

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4.33 Credentialing/Re-Credentialing

Providers are re-credentialed every three years and must complete the required reappointment application. Updates on malpractice coverage, state medical licenses and DEA certificates are also required. Please note that providers may not treat MCP members until they are credentialed. Providers must also be board certified.

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4.34 Licensure and Accreditation

Health delivery organizations such as hospitals, skilled nursing facilities, home health agencies and ambulatory surgical centers must submit updated licensure and accreditation documentation at least annually or as indicated.

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4.35 MercyOneSource

MCP provides a web-based platform enabling health plans to communicate healthcare information directly with providers. Users can perform transactions, download information, and work interactively with member healthcare information. The following information can be attained from the MercyOneSource platform:

  • Member Eligibility Search - Verify current eligibility on one or more members.
  • Panel Roster - View the list of members currently assigned to the provider as the primary care physician (PCP).
  • Provider List - Search for a specific health plan provider by name, specialty, or location.
  • Claim Status Search - Search for provider claims by member, provider, claim number, or service dates. Only claims associated with the user's account provider ID will be displayed.
  • Remittance Advice Search - Search for provider claim payment information by check number, provider, claim number, or check issue/service dates. Only remits associated with the user's account provider ID will be displayed.
  • Authorization List - Search for provider authorizations by member, provider, authorization data, or submission/service dates. Only authorizations associated with the user's account provider ID will be displayed.
  • Submit Authorizations - Submit an authorization request on-line. Three types of authorization types are available:
    • Medical Inpatient
    • Outpatient
    • DME - Rental

For additional information regarding MercyOneSource, please access the MercyOneSource Provider Web Navigation Guide under Mercy Care Plan/Provider Tools/Provider Notifications.

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CHAPTER 5 - COVERED AND NON COVERED SERVICES

5.0 Coverage Criteria

With the exception of emergency care, all covered services must be medically necessary and provided by a primary care provider or other qualified providers. Benefit limits apply.

Each line of business has specific covered and non-covered services. Participating providers are required to administer covered and non-covered services to members in accordance with the terms of their contract and member's benefit package.

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5.1 Covered Services

For a combined listing of covered services for MCP, please refer to Mercy Care Plan/Members Covered Benefits section on MCP’s website.

Providers may arrange medically necessary non-emergent transportation for MCP members by calling Member Services at (602) 263-3000 or (800) 624-3879, Express Service Code 630.

5.2 Non Covered Services
  • Services from a provider who is NOT contracted with MCP (unless prior approved by the Health Plan)
  • Cosmetic services or items;
  • Personal care items such as combs, razors, soap etc.;
  • Any service that needs prior authorization that was not prior authorized;
  • Services or items given free of charge, or for which charges are not usually made;
  • Services of special duty nurses, unless medically necessary and prior authorized;
  • Physical therapy that is not medically necessary;
  • Routine circumcisions;
  • Services that are determined to be experimental by the health plan medical director;
  • Abortions and abortion counseling, unless medically necessary, pregnancy is the result of rape or incest, or if physical illness related to the pregnancy endangers the health of the mother;
  • Health services if you are in prison or in a facility for the treatment of tuberculosis;
  • Experimental organ transplants, unless approved by AHCCCS;
  • Sex change operations;
  • Reversal of voluntary sterilization;
  • Medications and supplies without a prescription;
  • Treatment to straighten teeth, unless medically necessary and approved by MCP;
  • Prescriptions not on our list of covered medications, unless approved by MCP;
  • Physical exams for the purpose of qualifying for employment or sports activities;
  • Other Services that are Not Covered for Adults (age 21 and over);
  • Transplants for pancreas after liver transplant; lung transplants; allogeneic unrelated hematopoietic cell (bone marrow) transplants; liver transplants for members with a diagnosis of Hepatitis C; Heart transplants for non-ischemic cardiomyopathies; any other transplants not listed as covered;
  • Hearing aids, including bone-anchored hearing aids.
  • Cochlear implants;
  • Insulin pumps;
  • Most orthotics (exceptions included in MCP's Benefit Matrix);
  • Microprocessor controlled lower limbs and microprocessor controlled joints for lower limbs;
  • Percussive vests;
  • Services performed by a podiatrist;
  • Routine eye examinations for prescriptive lenses or glasses;
  • Outpatient Hospice - Effective 10/1/09 hospice for Acute Care adult members (21 years or older) is not covered.
  • Routine dental services and emergency dental services, unless related to the treatment of a medical condition such as acute pain, infection, or fracture of the jaw;
  • Well exams;
  • Chiropractic services (except for Medicare QMB members);
  • Outpatient speech and occupational therapy (except for Medicare QMB members).

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CHAPTER 6 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT)

6.0 EPSDT Program Overview

The Early and Periodic Screening, Diagnosis and Treatment program (EPSDT) applies to MCP members under age 21. The EPSDT program is governed by federal and state regulations and community standards of practice. All PCPs who provide services to members under age 21 are required to provide comprehensive health care, screening and preventive services, including, but not limited to:

  • Primary prevention
  • Early intervention
  • Diagnosis
  • All services required to treat or improve a defect, problem or condition identified in an EPSDT screening.

Please refer to the MCP website for Claims Coding for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Well-Child Visits under Mercy Care Plan/Provider Tools/Provider Notifications section for specific claim codes.

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6.1 Requirements for EPSDT Providers

PCPs are required to comply with regulatory requirements and MCP preventative requirements which include:

  • Documenting immunizations into Arizona State Immunization Information System (ASIIS) and enroll every year in the Vaccine for Children Program.
  • Providing all screening services according to the AHCCCS Periodicity Schedule and community standards of practice. The Periodicity Schedule can viewed by accessing the AHCCCS' website by clicking here.
  • Ensuring all infants receive both the first and second newborn screening tests. Specimens for the second test may be drawn at the PCP's office and mailed directly to the Arizona State Laboratory, or the member may be referred to MCP's contracted laboratory for the draw.
  • Using current AHCCCS standardized EPSDT tracking forms to document services provided and compliance with AHCCCS standards. The EPSDT tracking forms are available under Mercy Care Long Plan/Provider Tools/Forms on MCP’s website. They are also available on the AHCCCS website.
  • Sending copies of EPSDT tracking forms to MCP on a monthly basis.
  • Using all clinical encounters to assess the need for EPSDT screening and/or services.
  • Documenting in the medical record the member's decision not to participate in the EPSDT program, if appropriate.
  • Making referrals for diagnosis and treatment when necessary and initiate follow-up services within 60 days.
  • Scheduling the next appointment at the time of the current office visit for children 24 months of age and younger.
  • Reporting all EPSDT encounters on required claim forms, using the Preventive Medicine Codes.
  • Referring MCP members (Acute and DD) to Children's Rehabilitative Services (CRS) when they have conditions covered by the CRS program.
  • Referring members to WIC, AzEIP and Head Start as appropriate.
  • Initiating and coordinating referrals to behavioral health providers as necessary.

An EPSDT screening includes the following basic elements:

  • Comprehensive health and developmental history, including growth and development screening (includes physical, nutritional and behavioral health assessments).
  • PEDS evaluation for NICU graduates.
  • Comprehensive unclothed physical examination.
  • Appropriate immunizations according to age and health history.
  • Laboratory tests appropriate to age and risk for the following: blood lead, tuberculosis skin testing, anemia testing and sickle cell trait.
  • Health education and counseling about child development, healthy lifestyles and accident and disease prevention.
  • Appropriate dental screening and referral.
  • Appropriate vision and hearing/speech testing.
  • Obesity screening using the BMI percentile for children.
  • Anticipatory guidance.

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6.2 Health Education

The PCP is responsible for ensuring that health counseling and education are provided at each EPSDT visit. Anticipatory guidance should be provided so that parents or guardians know what to expect in terms of the child's development. In addition, information should be provided regarding accident and disease prevention, and the benefits of a healthy lifestyle.

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Screenings

6.3 Periodic Screenings

The AHCCCS EPSDT Periodicity Schedule specifies the screening services to be provided at each stage of the child's development. The AHCCCS EPSDT Periodicity Schedule (Exhibit 430-1) can be viewed at the AHCCCS website, http://azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400.pdf under Policy 430. This schedule follows the Center for Disease Control (CDC) recommendation. Children may receive additional inter-periodic screening at the discretion of the provider. MCP does not limit the number of well-child visits that members under age 21 receive, but they should be provided only once per year. Claims should be billed with the following CPT/ICD-9-CM Diagnosis Codes based on age appropriateness:

Codes to Identify Well-Child Visits – Ages 0 – 15 Months
CPT ICD-9-CM Diagnosis
99381, 99382, 99391, 99392, 99461 V20.2, V20.3, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Codes to Identify Well-Child Visits – Ages 3 – 6 Years
CPT ICD-9-CM Diagnosis
99382, 99383, 99392, 99393 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Codes to Identify Well-Care Visits - Adolescents
CPT ICD-9-CM Diagnosis
99383-99385, 99393-99395 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

For children up to age 21, the EPSDT Periodicity Schedule should be followed. Well Child Visits should be scheduled not less than one year after the last Well Child Visit. The visit should be completed in accordance with the recommendations in the schedule, i.e., different care and services such as vaccinations, at different ages.

Well Child Visits for sports and other activities should be based on the most recent EPSDT Well Child Visit, as the annual Well Child Visits are comprehensive and should include all of the services required for sports or other activities. AHCCCS does not cover sports or other physicals solely for that purpose. If it can be combined with a regularly scheduled EPSDT visit, it is covered, though no additional payment would be allowable for completing the school or other organization paperwork that would allow the child to participate in the activity.

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6.4 Nutritional Assessment & Nutritional Therapy

MCP covers nutritional therapy for EPSDT members on an enteral, parenteral or oral basis when determined medically necessary to provide either complete daily dietary requirements, or to supplement a member's daily nutritional and caloric intake. The following requirements apply:

  • Must be assessed at each visit.
  • Members in need of nutritional therapy should be identified and referred to MCP.
  • Nutritional therapy requires prior authorization and approval by the MCP Medical Director.
  • Once prior authorization has been attained, a fully completed Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form should be filled out and sent directly to the Durable Medical Equipment provider for handling. The form is available at MCP's web site Mercy Care Plan/Provider Tools/Forms or are available on the AHCCCS website at: http://azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400.pdf.

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6.5 Parents' Evaluation of Developmental Status (PEDS)

As of January 1, 2006, the PEDS Developmental Screening Tool should be utilized for developmental screening for EPSDT-age members admitted to the Neonatal Intensive Care Unit (NICU) following birth. The PEDS screening should be completed for NICU graduates from birth through eight (8) years of age.

  • Always complete the PEDS Tool as well as child screenings for NICU graduates.
  • Make a copy of the PEDS Tool and send it to MCP with the EPSDT form.

Providers receive additional reimbursement for use of the PEDS Tool when the following criterion is met:

  • Member is a NICU graduate born 1/1/06 or after;
  • Provider is PEDS trained; and
  • The code is appropriately billed (96110-EP)

PCPs may elect to use the PEDS Tool to assess members that are not NICU graduates, however, all of the above criteria must be met for reimbursement. MCP assists members with PCP selection to ensure that they are assigned to a PEDS trained provider when appropriate. MCP also monitors provider compliance of assessing NICU graduates using the PEDS Tool. A list of NICU graduates assigned to the providers' panel during the previous month is sent out on a monthly basis to the assigned PCP. Questions regarding a member's status as a NICU graduate should be directed to the EPSDT Coordinator. Additional information regarding the PEDS Developmental Screening Tool can be attained by accessing:

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6.6 Pediatric Immunizations/Vaccines for Children Program

EPSDT covers all child and adolescent immunizations. Immunizations must be provided according to the Advisory Committee on Immunization Practices (ACIP) guidelines and be up-to-date. Providers are required to coordinate with the Arizona Department of Health Services' (ADHS) Vaccine for Children Program (VFC) to obtain vaccines for MCP members who are 18 years of age and under.

Additional information can be attained by calling VFC at (602) 364-3642 or by accessing their website at www.azdhs.gov.

Arizona law requires the reporting of all immunizations administered to children under 19 years old. Immunizations must be reported at least monthly to ADHS. Reported immunizations are held in a central database, the Arizona State Immunization Information System (ASIIS) that can be accessed online to obtain complete, accurate records.

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6.7 Body Mass Index (BMI)

Providers should calculate each child's BMI starting at age three until the member is 21 years old. Body mass index is used to assess underweight, overweight, and those at risk for overweight. BMI for children is gender and age specific. PCPs are required to calculate the child's BMI and percentile. Additional information is available at the CDC website, www.cdc.gov.

The following established percentile cutoff points are used to identify underweight and overweight in children:

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6.7 - Body Mass Index (BMI) Table
Underweight BMI-for-age < 5th percentile
At risk of overweight BMI-for-age 85th percentile to < 95th percentile
Overweight BMI-for-age > 95th percentile
If a child is determined to be below the 5th percentile, or above the 85th percentile, the PCP should provide guidance to the member's parent or guardian regarding diet and exercise for the child. Additional services may be provided or referrals made if medically necessary.

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6.8 Blood Lead Screening

All children are considered at risk of, and must be screened for lead poisoning.

  • Children between 12 months of age and 24 months of age must receive a blood lead test.
  • Children between 36 months and 72 months of age must receive a blood lead test if they have not been previously screened.

A verbal risk assessment must be completed at each EPSDT visit for children six months through 72 months to determine risk category and the need for any follow up services.

Providers must report blood lead levels equal to or greater than 10 micrograms of lead per deciliter of whole blood to the ADHS.

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6.9 Eye Examinations and Prescriptive Lenses

EPSDT includes eye exams and prescriptive lenses to correct or ameliorate defects, physical illness and conditions. PCPs are required to perform basic eye exams and refer members to the contracted vision provider for further assessment.

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6.10 Hearing/Speech Screening

Hearing evaluation consists of appropriate hearing screens given according to the EPSDT schedule. Evaluation consists of history, risk factors, parental questions and impedance testing.

  • Pure-tone testing should be performed when medically necessary.
  • Speech screening shall be performed to assess the language development of the member at each EPSDT visit.

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6.11 Behavioral Health Screening

Screenings for mental health and substance abuse problems are to be conducted at each EPSDT visit. Treatment services are a covered benefit for members under age 21. The PCP is expected to:

  • Initiate and coordinate necessary referrals for behavioral health services.
  • Monitor whether a member has received services.
  • Keep any information received from a behavioral health provider regarding the member in the member's medical record.
  • Initial and date copies of referrals or information sent to a behavioral health provider before placing in the member's medical record.
  • If the member has not yet been seen by the PCP, this information may be kept in an appropriately labeled file in lieu of actually establishing a medical record, but must be associated with the member's medical record as soon as one is established.

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6.12 Dental Screening and Referrals

Oral health screenings are to be conducted at every EPSDT visit. The PCP must screen children less than three years of age at each visit to identify those who require a dental referral for evaluation and treatment.

In addition to the screening, members three years of age and older must be referred to a dentist at least annually. American Association of Pediatric dentistry recommends that the dental visits begin by age one but the referral isn't mandatory until age 3. Documented dental findings and treatment must be included in the member's medical record in the PCP's office. Depending on the results of the oral health screening, referral to a dentist should be made according to the following timeframes:

  • Urgent - (Within 24 hours) Pain, infection, swelling and/or soft tissue ulceration of approximately two weeks duration or longer
  • Early - (Within three weeks) Decay without pain, spontaneous bleeding of the gums and/or suspicious white or red tissue areas
  • Routine - (Next regular checkup) none of the above problems identified.

The member's parent or guardian may also self-refer and schedule dental appointments for the member with any MCP contracted general dentist. They may go directly to the dentist without seeing the PCP first and no authorization is required.

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6.13 Tuberculin Skin Testing

Tuberculin skin testing should be performed as appropriate to age and risk. Children at increased risk of tuberculosis (TB) include those who have contact with persons:

  • Confined or suspected of TB;
  • In jail during the last five years;
  • Living in a household with an HIV-infected person or the child is infected with HIV; and
  • Traveling/emigrating from, or having significant contact with persons indigenous to, endemic countries.

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State Programs

6.14 Arizona Early Intervention Program (AzEIP)

AzEIP is an early intervention program that offers a statewide system of support and services for children birth through three years of age and their families who have disabilities or developmental delays. Although anyone can refer a child, PCPs should refer to AzEIP when developmental delays are identified during EPSDT screenings.

After a referral has been made, the family is contacted and an initial meeting is set up to begin the initial planning process (IPP). During the IPP process, the child is assessed and eligibility is determined. If eligible, a service coordinator is assigned to the family and works with other team members to develop outcomes for the child. The Individualized Family Service Plan (IFSP) is developed during the IPP and PCPs will receive a copy of the document.

PCPs are responsible for coordinating EPSDT covered services recommended in the IFSP when requested by the AzEIP Service Coordinator or MCP. The IFSP includes:

  • The child's present physical, cognitive and social/emotional development.
  • The family's resources, priorities and concerns.
  • The expected outcomes for the child and family.
  • Specific early intervention services necessary to meet the child's unique needs.
  • The environment in which the early intervention services will be provided.
  • Transition plan outlining steps for moving from one setting/program to another and the projected dates of transition.
  • Identification of the service coordinator who will be responsible for the implementation of the plan and coordination with other agencies and persons.

MCP coordinates with AzEIP to ensure that members receive medically necessary EPSDT services in a timely manner to promote optimum child health and development. Requests from MCP submitted to the PCP must be responded to by the date indicated on the request. For additional information, please contact the EPSDT Coordinator.

Please refer to Mercy Care Plan/Provider Tools/Provider Notifications, Arizona Early Prevention Program on MCP’s website for additional information regarding referrals and locations.

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6.15 Children's Rehabilitative Services (CRS)

Beginning October 1, 2008, Arizona Physicians IPA (APIPA) was contracted by the AZ Department of Health Services to administer the Children's Rehabilitation Services (CRS) program. APIPA is responsible to provide oversight for quality of care, prior authorization for services provided to CRS eligible children for CRS eligible conditions provided by CRS contracted providers and clinics, utilization management, and claims payment for services provided through a CRS Clinic or CRS practitioner. Members do not need to change from MCP to obtain CRS services.

All other services for MCP members will continue to be provided through MCP network providers including EPSDT screenings and well-child visits, immunizations, and medical services for a member's illness or injury. Members currently enrolled with MCP do not need to leave the health plan in order to continue getting services for a CRS condition or through CRS clinics or practitioners that are not administered by APIPA.

To contact APIPA for more information about their administration of CRS services, visit their website www.myapipacrs.com, or call: (800) 445-1638.

Providers are responsible for referring children with eligible conditions to the CRS program and are strongly encouraged to do so. All PCP referrals to CRS must be documented in the member's medical record.

Complete an Application/Referral Form available on the APIPA website and submit with:

  • A completed CRS application
  • A copy of the member's medical record

Eligibility requirements include a condition that requires comprehensive multi-disciplinary care and is a condition that has a reasonable potential for rehabilitation. Examples of medical conditions covered under the CRS program include:

  • Club foot
  • Scoliosis
  • Cerebral palsy
  • Cleft lip/palate
  • Cystic Fibrosis
  • Spina Bifida
  • Neurofibromatosis
  • Metabolic diseases (Phenylketonuria, Galactosemia)

For questions regarding CRS coverage, or assistance with the referral process, please contact the MCP CRS cordinator at (602) 659-9107 or the Department of Health Services/Office for Children with Special Health Care Needs at (602) 542-1860.

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6.16 AHCCCS Office of Special Programs

Children who have been diagnosed with the following genetic metabolic conditions and who need medical foods may receive services directly through the AHCCCS Office of Special Programs. AHCCCS covers medical foods, within the limitations specified in the AHCCCS Medical Policy Manual (AMPM), Chapter 320-H, titled Medical Foods, for any member diagnosed with one of the following inherited metabolic conditions:

  • Phenylketonuria
  • Homocystinuria
  • Maple Syrup Urine Disease
  • Galactosemia (requires soy formula)
  • Beta Keto-Thiolase Deficiency
  • Citrullinemia
  • Glutaric Acidemia Type I
  • 3 Methylcrotonyl CoA Carboxylase Deficiency
  • Isovaleric Acidemia
  • Methylmalonic Acidemia
  • Propionic Acidemia
  • Arginosuccinic Acidemia
  • Tyrosinemia Type I
  • HMG CoA Lyase Deficiency
  • Cobalamin A, B, C Deficiencies

Metabolic Disorder Medical Foods - Coverage Entity:

  • Members receiving EPSDT and KidsCare services that have been diagnosed with a metabolic disorder included in the AMPM, Chapter 320-H, Medical Foods, are eligible for services through CRS.
  • Members receiving EPSDT services and KidsCare members must receive metabolic formula through CRS.
  • Members receiving EPSDT services and KidsCare members who require modified low protein foods receive them through AHCCCS Administration.
  • AHCCCS Administration is responsible for providing both necessary metabolic formula and modified low protein foods for members 21 years of age and older who have been diagnosed with one of the inherited metabolic disorders included in the AMPM, Chapter 320-H, Medical Foods section.
    • MCP is responsible for initial and follow-up consultations by a genetics physician and/or a metabolic nutritionist, lab tests and other services related to the provision of medical foods for enrolled members diagnosed with a metabolic disorder included in the AMPM, Chapter 320-H, Medical Foods section.

Further information can be obtained by contacting the Office of Special Programs at (602) 417-4053 or by referring to the AHCCCS Medical Policy Manual and referring to Chapter 320-H, Medical Foods.

CHAPTER 7 - BEHAVIORAL HEALTH

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7.0 Behavioral Health Overview

Comprehensive mental health and substance abuse (behavioral health) services are available to MCP members. If a member is enrolled in MCP's Acute Care or DDD programs, the Regional Behavioral Health Authority (RBHA) delivers behavioral health (mental health and substance abuse) services to these members. Effective October, 1, 2010, AHCCCS will automatically assign all Acute Care enrolled members into RBHA. will be assigned based on the zip code in which they reside and the RBHA they are assigned to will be identified on the Member's ID Card.

As a result of automatic RBHA enrollment, the RBHA will assume financial responsibility for all behavioral health services upon enrollment with AHCCCS. Additionally, services in the prior period which have historically been covered by Mercy Care will now be the responsibility of the RBHA.

For more information related to the AHCCCS Behavioral Health Program, visit:

Link

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7.1 Behavioral Health Screening

Medically necessary health and behavioral assessment procedures are covered services when used to identify the psychological, behavioral, emotional, cognitive and social factors important to the prevention, treatment and management of physical health problems.

  • Members should be screened by their PCP for behavioral health needs during routine or preventive visits.
  • Behavioral health screening is required as a part of the EPSDT screening services for members under age 21

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7.2 Emergency Services

When members present in an emergency room setting, MCP is responsible for all emergency medial services including triage, physicians assessment and diagnostic tests. In addition, MCP is responsible to ensure member does not run out of medication prior to the member’s initial first appointment with RBHA. ADHS/RBHA is responsible for medically necessary psychiatric consultations in emergency room settings.

Reimbursement for court ordered screening and evaluation services is not the responsibility of MCP and is instead the RBHA responsibility of the limited county pursuant to A.R.S. 36-545.

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7.2 - AHCCCS Acute and DDD Patient Psychiatric and Detoxification Services Crosswalk
Patient Entity responsible for payment:
Primary condition is medical with the need for detoxification secondary MCP is responsible
Patient requires detoxification and primarily condition is not medical RBHA is responsible for detoxification stay.
Patient requires inpatient psychiatric care RBHA is responsible for inpatient psychiatric care.

Please refer to the AHCCCS Behavioral Health Services Guide for additional information. This guide can be obtained via the AHCCCS website at www.ahcccs.state.az.us.

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7.3 Behavioral Health Medication Monitoring and Pharmacy Benefits

PCPs may provide medication management (prescription of behavioral health medications, monitoring visits, associated laboratory tests) for MCP acute care and DDD members with attention deficit hyperactivity disorder (ADHD), anxiety, depression or post partum depression. PCPs may also make a referral to a RBHA for services to treat these conditions.

  • MCP covers prescriptions of these four behavioral health conditions when on the Preferred Drug List. Prior authorization is required for medications not on the preferred drug list.
  • The Preferred Drug List may be accessed through Epocrates.
  • Prescriptions can be filled at any contracted MCP pharmacy.

Members who have a behavioral health condition other than the four disorders above, will be covered through the RBHA for medication management and treatment.

Requirements for PCPs Providing Care to Acute and DDD Members

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7.4 Clinical Guidelines

PCPs that provide treatment and medication management for ADHD, anxiety and depression must follow Clinical Guidelines adopted by MCP for those conditions. The guidelines are kept current and are available on the MCP website. MCP's behavioral health coordinators and behavioral health medical director are available for consultation regarding the guidelines. Please refer to the Mercy Care Plan/Provider Tools/Provider Notification titled Behavioral Health Approved Diagnoses List for Primary Care Physician Services for additional information.

7.5 Behavioral Health Records

A medical record must be established by the PCP for assigned members when behavioral health information is received from the RBHA or a RBHA provider, even if the member has not yet been seen by the PCP. The behavioral health information must be included as a part of that record. If a medical record has not been established for the member, behavioral health information may be maintained in an appropriately labeled file and incorporated in the medical record when it is established.

Providers should:

  • Initial and date incoming documents from the RBHA or RBHA provider related to behavioral health treatment to demonstrate that the records have been reviewed
  • Document coordination of care efforts and further treatment recommendations in the member's medical record.
  • Respond within 10 business days to the RBHA or RBHA provider requests for a member's medical information such as current diagnosis, medication, pertinent laboratory results, last PCP visit and last hospitalization.
  • Treat all member behavioral health records and transfer of information with confidentiality, in accordance with Health Insurance Portability and Accountability Act (HIPAA) guidelines.

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7.6 Required PCP Protocols and Procedures for RBHA Referrals and Transition of Care

Providers must establish and implement protocols and procedures to use when:

  • Referring a member to the RHBA.
  • Transitioning a member's care for a behavioral health need to the RBHA.
  • Coordinating care for MCP members in their patient panel who are receiving behavioral health services from the RBHA.

The protocols must address:

  • Criteria for a referral or transition of care.
  • Notification to the RBHA of the referral/transition.
  • Transitioning of prescriptions for current medications.
  • Timeframes for dispensing and refilling medications during the transition period.

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7.7 Referral of a Member to the RBHA

Acute Care or DD members of any age may be referred to the RBHA. Referrals to the RBHA for screening, evaluation and treatment may be initiated by:

  • A PCP;
  • Mercy Care Plan;
  • The member or their parent/guardian; or
  • Schools, state agencies or other service providers.

The RBHA Referral Form for Acute and DD members may be mailed or faxed directly to the RBHA and is available on MCP’s website under Mercy Care Plan/Provider Tools/Forms. There are two forms available along with instructions on how to fill out:

  • RBHA Referral Form - Maricopa County Only
  • RBHA Referral Form - Non-Maricopa Counties Only

MCP will provide transportation to a member's first RBHA evaluation appointment if a member is unable to provide his/her own transportation.

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7.8 Guidelines for Referring a Member to the RBHA
  • Use the above mentioned forms to refer a member.
  • Provide copies of all applicable records to the RBHA provider per HIPAA guidelines, including but not limited to, the reason for referral, diagnostic information, medical history, medication history and all current prescriptions that have been provided for the member.
  • Develop a plan for transition of care if medication management is being transferred.
  • Coordinate the transfer of care and ensure at a minimum, that the member does not run out of prescribed medications prior to the first appointment with a RHBA prescriber. An appointment for a member to be seen by a RBHA prescriber may take up to 30 days or longer. Therefore the PCP's oversight of member continuity of care during the transition of care is of utmost importance.
  • Members may also be referred to the RBHA for concurrent therapy and counseling services while receiving medication management through their PCP. In these circumstances, coordination of care is again of the utmost importance.
  • PCPs are required to refer and transition a member's behavioral health care to the RBHA for members who:
    • Have been admitted to an inpatient hospital for a behavioral health diagnosis.
    • Do not respond to treatment and therefore need additional behavioral health services such as counseling and/or more intense medication monitoring.
    • Present with a behavioral health diagnosis other than ADHD, anxiety, depression, or post partum depression.
    • Have experienced a sentinel event (e.g. attempted suicide).
    • Require services outside the PCP's scope of expertise.
  • The transition period to the RBHA provider should take place within 30 days, and no later than 90 days. PCPs will receive a return fax with a "Notification of Assessment" after a referral form has been faxed to the RBHA.
  • PCPs should maintain documentation in the member's medical record related to:
    • Ongoing treatment during the transition period;
    • The date that the member was referred;
    • The reason the member was referred;
    • Receiving contact name and pertinent information/
    • The date that the medical record was forwarded to the RBHA; and
    • Any other pertinent information.
  • If the PCP does not receive feedback from the RBHA, the medical record must reflect that follow-up was initiated by the PCP with the RBHA and/or the member to inquire about the status of the referral.
  • If there is a problem in communicating with the local RBHA regarding a particular referral, contact the MCP behavioral health coordinator for assistance.

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7.9 Behavioral Health

Consultation regarding treatment options, medications, referrals, and transition of care is also available from the RBHA. This may include a telephone consult, a face-to-face evaluation of a member by a psychiatrist, or a comprehensive assessment of the member by the RBHA evaluation specialist. PCPs should specify what information they are seeking, e.g. diagnostic consultation, medication recommendations, or other treatment recommendations.

To obtain a behavioral health consultation from the RBHA, PCPs should:

  • Contact the RBHA directly and request a consultation, and/or
  • Fax the RBHA referral form directly to the RBHA (see instructions above regarding this form).

For questions regarding member referrals to the RBHA for general behavioral health services (nonemergency), transition of care or coordination of care issues, please contact the MCP behavioral health coordinator.

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7.10 RBHA Services for Mercy Care Plan Acute and DD Members

The RBHA is responsible for screening and evaluation of members to determine their eligibility to receive behavioral health services from RBHA providers. In addition to screening and evaluation, RBHA provides comprehensive behavioral health services including:

  • Behavior management (behavioral health personal care, family support/home care training, self-help/peer support)
  • Behavioral health nursing services
  • Behavioral Health case management services (limited)
  • Emergency behavioral health care
  • Emergency/non-emergency transportation
  • Evaluation and assessment
  • Individual, group and family therapy and counseling
  • Inpatient hospital services
  • Non-hospital inpatient psychiatric facilities services (Level 1 residential treatment centers and sub-acute facilities)
  • Laboratory and radiology services for psychotropic medication regulation and diagnosis
  • Opioid Agonist treatment
  • Partial care (supervised day program, therapeutic day program, and medical day program)
  • Psychosocial rehabilitation (living skills training, health promotion, supportive employment services
  • Psychotropic medication
  • Psychotropic medication adjustment and monitoring
  • Respite care (with limitations)
  • Rural substance abuse transitional agency services
  • Screenings

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7.11 Diabetic members and the AZ State Hospital
  • Diabetic members who are admitted to the AZ State Hospital (AzSH) for behavioral health services will receive training to use a glucometer and testing supplies during their stay at AzSH.
  • Upon discharge from AzSH, PCPs must ensure these members are issued the same brand and model of glucometer and supplies that they were trained to use during their AzSH admission.
  • MCP's behavioral health coordinator will notify the PCP of the member's discharge from AzSH and provide information on the brand and model of equipment and supplies that should be continued to be prescribed.
  • The MCP behavioral health coordinator will work with AzSH to ensure the member has sufficient testing supplies to last until an office visit can be scheduled with the provider.
  • In the event the member's mental status renders them incapable or unwilling to manage their medical condition and that condition requires skilled medical care, the MCP behavioral health coordinator will work with AzSH, the member's RBHA and the PCP to obtain an appropriate placement or additional outpatient.

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7.12 Provider Coordination of Care

It is very important that PCPs develop a strong communication link with a member's behavioral health provider. PCPs are expected to exchange any relevant information such as medical history, current medications, diagnosis and treatment within 10 business days of receiving the request from the behavioral health provider.

Where there has been a change in a member's health status identified by a medical provider, there should be coordination of care with the behavioral health provider within a timely manner. The update should include but is not limited to; diagnosis of chronic conditions, support for the petitioning process, and all medication prescribed.

The PCP should also document and initial signifying review receipt of information received from a behavioral health provider who is treating the member. All efforts to coordinate on care on behalf of the member should be documented in the member's medical record.

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7.13 Family Involvement

Family involvement in a member's treatment is an important aspect in recovery. Studies have shown members who have family involved in their treatment tend to recover quicker, have less dependence on outside agencies, tend to rely less on emergency resources, and the level of behavioral health decompensation is not as severe. Family is defined as any person related to the member biologically or appointed (step-parent, guardian, power of attorney). Treatment includes treatment planning, participation in counseling or psychiatric sessions, providing transportation or social support to the member. Information can be shared with other parties with written permission from the member or the member's guardian.

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7.14 Court Ordered Treatment and Petition Process

At times a MCP member may need to be petitioned through the Mental Health Court.

Emergent Petition

For an Emergent Petition, which is defined as: "Only persons who, as a direct result of a mental disorder, display behaviors that are a Danger to Self or Danger to Others, and the person is likely, without IMMEDIATE hospitalization, to suffer serious physical harm or illness, or likely to inflict serious physical harm upon another person.", the provider will need to file the petition in person at one of the following facilities:

Urgent Psychiatric Care Center Center/ConnectionsAZ
(602) 416-7600
903 N. 2nd Street
Phoenix, AZ 85004

Psychiatric Recovery Center West/Recovery Innovations
(602) 416-7600
11361 N. 99th Avenue, Suite 402
Peoria, AZ 85345

Non-Emergent Petition

Non-Emergent Petitions are known as a Gravely Disabled or Persistently and Acutely Disabled (PAD) and are defined: "As a result of a mental disorder is likely to cause serious physical harm or illness because he/she is unable to provide for their basic needs, or if not treated has probability of causing the person to suffer severe mental, emotional, or physical harm, or impairs the person's capacity to extent they are incapable of understanding and expressing the consequence of accepting treatment." The Non-Emergent Petitions are filed by calling the EMPACT-SPC PAD line at (480) 784-1514, extension 1158 ("Non-Emergent Petition).

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CHAPTER 8 - FAMILY PLANNING

8.0 Family Planning Overview

Family planning services are provided through Schaller Anderson (SA), an Aetna Company. Family planning services are those services provided by health professionals to eligible persons who voluntarily choose to delay or prevent pregnancy. In order to allow members to make informed decisions, counseling should provide accurate, up-to-date information regarding available family planning methods and prevention of sexually transmitted diseases.

Additional information is located at: www.SchallerAnderson.com.

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8.1 Provider Responsibilities for Family Planning Services

All providers are responsible for:

  • Making appropriate referrals to health professionals who provide family planning services.
  • Keeping complete medical records regarding referrals.
  • Verifying and documenting a member's willingness to receive family planning services.
  • Providing medically necessary management of members with family planning complications. SOBRA Family Planning Extension Program members must be referred to low cost services within the community for medical services. A listing of these services is available on MCP's website under Mercy Care Plan/Provider Tools/Provider Notification titled Low Cost No Cost Health Care Referral List.
  • Notifying members of available contraceptive services and making these services available to all members of reproductive age using the following guidelines:
    • Information for members who are 17 years of age and younger must be given the information through the member's parent or guardian.
    • Information for members between 18 and 55 years of age must be provided directly to the member or legal guardian.
    • Whenever possible, contraceptive services should be offered in a broad-spectrum counseling context, which includes discussion of mental health and sexually transmitted diseases, including AIDS.
    • Members of any age whose sexual behavior exposes them to possible conception or STDs should have access to the most effective methods of contraception.
    • Every effort should be made to include male or female partners in such services.
  • Providing counseling and education to members of both genders that is age appropriate and includes information on:
    • Prevention of unplanned pregnancies.
    • Counseling for unwanted pregnancies. Counseling should include the member's short and long - term goals.
    • Spacing of births to promote better outcomes for future pregnancies.
    • Preconception counseling to assist members in deciding on the advisability and timing of pregnancy, to assess risks and to reinforce habits that promote a healthy pregnancy.
    • Sexually transmitted diseases, to include methods of prevention, abstinence, and changes in sexual behavior and lifestyle that promote the development of good health habits.
  • Contraceptives should be recommended and prescribed for sexually active members. PHPs are required to discuss the availability of family planning services annually. If a member's sexual activity presents a risk or potential risk, the provider should initiate an in-depth discussion on the variety of contraceptives available and their use and effectiveness in preventing sexually transmitted diseases (including AIDS). Such discussions must be documented in the member's medical record.

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8.2 Covered and Non Covered Services

Full health care coverage and voluntary family planning services are covered.

The following services are not covered for the purposes of family planning:

  • Treatment of infertility;
  • Pregnancy termination counseling;
  • Pregnancy terminations;
  • Hysterectomies;
  • Hysteroscopic tubal sterilization;
  • Services to reduce voluntary, surgically induced fertilized embryos.

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8.3 Prior Authorization Requirements

Prior authorization is required for family planning services, sterilization or pregnancy termination. Prior authorization must be obtained before the services are rendered or the services will not be eligible for reimbursement.

To obtain authorization for family planning services, please complete the Schaller Anderson Family Planning Services Prior Authorization Form, available on MCP’s website under the Mercy Care Plan/Provider Tools/Provider Notifications and fax requests to:

Schaller Anderson, an Aetna Company
(602) 431-7303: Phoenix

To obtain authorization for sterilization or pregnancy termination:

  • Complete applicable form(s)
    • For sterilization: Schaller Anderson Family Planning Services Prior Authorization Form listed above and the Consent for Sterilization Form. Permanent sterilization is only covered for MCP members 21 years of age or older.
    • For pregnancy termination: Schaller Anderson Family Planning Services Prior Authorization Form, listed above.
  • Fax completed prior authorization form and signed consent form prior to the procedure to:

    Schaller Anderson, an Aetna Company
    (602) 659-1965: Phoenix
    (800) 573-4165: Outside Phoenix

For members enrolled in the Department of Economic Security, Division of Developmental Disabilities (DES/DDD), health professionals must obtain prior authorization from the DES/DDD medical director prior to providing sterilization procedures for members enrolled with DES/DDD in addition to Schaller Anderson, an Aetna Company. Notification of approved requests will be faxed or mailed to the provider.

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8.4 SOBRA Family Planning Extension Services Program

Sixth Omnibus Budget Reconciliation Act (SOBRA) Family Planning Services Extension Program is provided through Schaller Anderson (SA), an Aetna Company. The SOBRA Family Planning Services Extension Program provides comprehensive family planning services only. Members may retain SOBRA Family Planning Services for up to a maximum of 24 months after SOBRA eligibility has terminated.

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8:4 - SOBRA Family Planning Extension Services Table
SERVICES
ACUTE CARE 		FEMALE MEMBERS * RECEIVING FAMILY PLANNING EXTENSION SERVICES
Pregnancy Screening Covered only when completed prior to provision of long-term contraceptives.
Pharmaceuticals Covered service only when associated with medical conditions related to family planning.
Screening and treatment for sexually transmitted diseases (STDs) Screening services for STDs are covered but treatment services are not provided through AHCCCS - a referral is made to an agency, which provides low or no cost STD treatment services.
Sterilization Services are covered for female members when the requirements specified in this policy for sterilization are met.

* SOBRA family planning extension services are available only to female members who have lost SOBRA eligibility for medical services; men are not eligible for these services.

Key Information about SOBRA Family Planning Services Extension Program

  • Women who receive services through the SOBRA Family Planning Services Extension Program are not eligible for full health care coverage, including treatment of any disease process.
  • If a diagnosis is made, the member must be referred to community clinics for treatment. MCP will mail the member a letter when their eligibility is about to terminate with a list of available community resources for medical care.
  • Members receive notification of eligibility for the program when their SOBRA eligibility expires, and once annually thereafter, for up to 24 months. Eligibility is determined annually. Members generally are enrolled with the same health plan they were enrolled with during their pregnancy.
  • Members are not assigned to a PCP or OB as they are only eligible for family planning services. They may obtain their family planning services from any health providers contracted with AHCCCS.
  • If a member has a permanent sterilization procedure, she is no longer eligible for the Family Planning Services Extension Program and AHCCCS will disenroll the member from MCP. Permanent sterilization procedures performed on program members will be reported to AHCCCS by Schaller Anderson (SA), an Aetna Company.
  • The SOBRA Family Planning Services Extension Program does not extend benefits to men.
  • Prior to the delivery of covered benefits, providers must verify enrollment. Failure to verify enrollment may result in unpaid claims. Claims for services provided to members who are not currently enrolled with MCP, other than SOBRA Family Planning Services, will not be paid even if a prior authorization number was issued. Members may be billed for non-covered services if the provider appropriately notified the member of their payment responsibility prior to the delivery of services. Issuance of prior authorization does not guarantee payment.

If you have questions about these or other family planning services, please contact:

Schaller Anderson, an Aetna Company
(602) 798-2745: Phoenix
(888) 836-8147: Outside Phoenix

A listing of Covered Family Planning Services and Appropriate Billing Codes is available on the MCP website under Mercy Care Plan/Provider Tools/Provider Notifications.

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CHAPTER 9 - MATERNITY

9.0 Maternity Overview

MCP assigns newly identified pregnant members to a PCP to manage their routine non-OB care. Members are assigned to an OB provider through the prior authorization process. The OB provider manages the pregnancy care for the member and is reimbursed in accordance with their contract and prior authorized services.

If a member chooses to have an OB as their PCP during their pregnancy, MCP will assign the member to an OB PCP. If an OB provider has obtained authorization for OB services for a pregnant member and the member is assigned to the practice, the member will remain with their OB PCP until after their post partum visit when they will return to their previously assigned PCP.

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9.1 High Risk Maternity Care

In partnership with OB providers, MCP case managers identify pregnant women who are "at risk" for adverse pregnancy outcomes. MCP offers a multi-disciplinary program to assist providers in managing the care of pregnant members who are at risk because of medical conditions, social circumstances or non-compliant behaviors. MCP also considers factors such as noncompliance with prenatal care appointments and medical treatment plans in determining risk status. Members identified as "at risk" are reviewed and evaluated for ongoing follow up during their pregnancy by an obstetrical case manager.

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9.2 OB Case Management

Obstetrical case managers link expectant mothers with appropriate community resources such as the Women, Infants and Children's (WIC) nutritional program, parenting classes, smoking cessation, teen pregnancy case management, shelters and substance abuse counseling. They provide support, promote compliance with prenatal appointments, and prescribe medical regimens. Under most circumstances, the high risk screening should be performed at the first prenatal appointment. Identification of a high risk case may also be based on prior knowledge of the member's medical/prenatal history, or an initial telephone screening. MCP may prior authorize a referral from a general OB for a consult or transfer of a pregnant member to a perinatologist for "Total OB Care" for certain medical conditions or circumstances, including but not limited to:

  • Insulin dependent diabetes
  • Chronic renal disease or renal insufficiency
  • Epilepsy requiring medication
  • Chronic hypertension requiring medication
  • A history of delivering two or more infants at 32 weeks or less
  • A malignancy
  • A current diagnosis of highly probable Intrauterine Growth Retardation (IUGR)
  • Premature rupture of the membranes (before 32 weeks)
  • Pregnant with triplets or more
  • Potential need for cerclage procedure
  • Diagnosis of Lupus Erythematosus
  • Twin pregnancy with diagnosis of discordant growth
  • HIV positive mother
  • Polyhydramnios
  • Oligohydramnios

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9.3 OB Incentive Program

MCP offers a $25 incentive payment to OB providers for each copy of a completed ACOG/MICA form submitted to the MCP Case Management department prior to the end of the third month of pregnancy (first trimester). This special program is designed to identify high risk pregnancies as early as possible and to enroll at risk pregnant members in MCP's prenatal case management. Documentation on the form is to be complete and legible. Members identified as "at risk" are reviewed and evaluated for ongoing follow up during their pregnancy by an obstetrical case manager.

Please contact MCP Perinatal Case Management at (480) 654-2508 in order to make any referrals. All OB incentive questions should be directed to (602) 840-0520. You must include your provider tax identification number and payee (where payment should be made) when submitting invoices.

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9.4 Obstetrical Care Appointment Standards

MCP has specific standards for the timing of initial and return prenatal appointments. These standards are as follows:

Initial Visit

All OB providers must make it possible for members to obtain initial prenatal care appointments within the time frames identified:

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9:4 - Pre-Natal Care Appointment Availability Table
Category Appointment Availability
First trimester Within 14 days of the request for an appointment
Second trimester Within seven days of the request for an appointment
Third trimester Within three days of the request for an appointment
Return Visits Return visits should be scheduled routinely after the initial visit. Members must be able to obtain return prenatal visits: First 28 weeks - every four weeks
From 28 to 36 weeks - every two to three weeks
From 37 weeks until delivery - weekly
High Risk Pregnancy Care

Within three days of identification of high risk by the Contractor or maternity care provider, or immediately if an emergency exists.

Return visits scheduled as appropriate to their individual needs; however, no less frequently than listed above.
Postpartum Visits Postpartum visits should be scheduled routinely after delivery. Routine postpartum visits should be scheduled within 21 and 60 days after delivery.

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9.5 General Obstetrical Care Requirements

All providers must adhere to the standards of care established by the American College of Obstetrics and Gynecology (ACOG), which include, but are not limited to the following:

  • Use of a standardized prenatal medical record and risk assessment tool, such as the ACOG Form, documenting all aspects of maternity care.
  • Completion of history including medical and personal health (including infections and exposures), menstrual cycles, past pregnancies and outcomes, family and genetic history.
  • Clinical expected date of confinement.
  • Performance of physical exam (including determination and documentation of pelvic adequacy).
  • Performance of laboratory tests at recommended time intervals.
  • Comprehensive risk assessment incorporating psychosocial, nutritional, medical and educational factors.
  • Routine prenatal visits with blood pressure, weight, fundal height (tape measurement), fetal heart tones, urine dipstick for protein and glucose, ongoing risk assessment with any change in pregnancy risk recorded and an appropriate management plan.

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9.6 Additional Obstetrical Physician and Practitioner Requirements
  • Educate members on healthy behaviors during pregnancy, including proper nutrition, effects of alcohol and drugs, the physiology of pregnancy, the process of labor and delivery, breast feeding and other infant care information.
  • Offer HIV/AIDS testing and confidential post testing counseling to all members.
  • Ensure delivery of newborn meets MCP criteria.
  • Remind delivery hospital of requirement to notify MCP on the date of delivery.
  • Refer member to MCP case management, and other known support services and community resources, as needed.
  • Encourage members to participate in childbirth classes at no cost to them. The member may call the facility where she will deliver and register for childbirth classes.

Providers may also consult with a MCP medical director for members with other conditions that are deemed appropriate for perinatology referral. Please call (602) 263-3000 or (800) 624-3879 with requests for assignment to a perinatologist.

In non-emergent situations, all obstetrical care physicians and practitioners must refer members to MCP providers. Referrals outside the contracted network must be prior authorized. Failure to obtain prior authorization for non-emergent OB or newborn services out of the network will result in claim denials. Members may not be billed for covered services if the provider neglects to obtain the appropriate approvals.

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9.7 Provider Requirements for Medically Necessary Termination of Pregnancy

Medically necessary pregnancy termination services are provided through Schaller Anderson (SA), an Aetna Company. An SA Medical Director will review all requests for medically necessary pregnancy terminations. Documentation must include:

  • A copy of the member's medical record;
  • A completed and signed copy of the AHCCCS Certificate of Medical Necessity for Pregnancy Termination, available at the following website: Link.
  • Written explanation of the reason that the procedure is medically necessary. For example, it is:
    • Creating a serious physical or mental health problem for the pregnant member.
    • Seriously impairing a bodily function of the pregnant member.
    • Causing dysfunction of a bodily organ or part of the pregnant member.
    • Exacerbating a health problem of the pregnant member.
    • Preventing the pregnant member from obtaining treatment for a health problem.

If the pregnancy termination is requested as a result of incest or rape, the following information must be included:

  • Identification of the proper authority to which the incident was reported, including the name of the agency.
  • the report number.
  • the date that the report was filed.

When termination of pregnancy is considered due to rape or incest, or because the health of the mother is in jeopardy secondary to medical complications, please contact SA at (602) 798-2745 or (888) 836-8147. All terminations requested for minors must include a signature of a parent or legal guardian or a certified copy of a court order.

For members enrolled in the Department of Economic Security, Division of Developmental Disabilities (DES/DDD), Health Professionals must obtain prior authorization from the DES/DDD medical director prior to providing termination procedures for members enrolled with DES/DDD, in addition to Schaller Anderson, an Aetna Company.

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9.8 Reporting High Risk and Non-Compliant Behaviors

Obstetrical physicians and practitioners must refer all "at risk" members to MCP's Case Management department by calling (602) 263-3000 or (800) 624-3879 and selecting the option for maternity care. Providers may also fax their information to (602) 351-2313. The following types of situations must be reported to MCP for members that:

  • Are diabetic and display consistent complacency regarding dietary control and/or use of insulin.
  • Fail to follow prescribed bed rest.
  • Fail to take tocolytics as prescribed or do not follow home uterine monitoring schedules.
  • Admit to or demonstrate continued alcohol and/or other substance abuse.
  • Show a lack of resources that could influence well being (e.g. food, shelter and clothing).
  • Frequently visit the emergency department/urgent care setting with complaints of acute pain and request prescriptions for controlled analgesics and/or mood altering drugs.
  • Fail to appear for two or more prenatal visits without rescheduling and fail to keep rescheduled appointment. Providers are expected to make two attempts to bring the member in for care prior to contacting the MCP Case Management Department.

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9.9 Outreach, Education and Community Resources

MCP is committed to maternity care outreach. Maternity care outreach is an effort to identify currently enrolled pregnant women and to enter them into prenatal care as soon as possible. PCPs are expected to ask about pregnancy status when members call for appointments, report positive pregnancy tests to MCP and to provide general education and information about prenatal care, when appropriate, during member office visits. Pregnant members will be assigned an OB provider through the prior authorization process, but will continue to receive primary care services from their assigned PCP during their pregnancy.

MCP is involved in many community efforts to increase the awareness of the need for prenatal care. PCPs are strongly encouraged to actively participate in these outreach and education activities, including:

  • The Baby Arizona Program - It is designed to bring women into prenatal care early. To become a Baby Arizona provider or to learn more about the program, go to http://www.babyarizona.gov/. Once enrolled in the program, please notify your Provider Relations Representative so that Mercy Care Plan may properly identify your enrollment.
  • The WIC Nutritional Program - Please encourage members to enroll in this program.

Various other services are available in the community to help pregnant women and their families. Please call MCP's Case Management department for information about how to help your patients use these services. The Low Cost No Cost Health Care Referral List can be accessed under Mercy Care Plan/Provider Tools/Provider Notification section on MCP’s website.

Questions regarding the availability of community resources may also be directed to the Arizona Department of Health Services (ADHS) Hot Line at (800) 833-4642.

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9.10 Providing EPSDT Services to Pregnant Members Under Age 21

Federal and state mandates govern the provision of EPSDT services for members under the age of 21 years. The provider is responsible for providing these services to pregnant members under the age of 21, unless the member has selected an OB provider to serve as both the OB and PCP. In that instance, the OB provider must provide EPSDT services to the pregnant member.

Additional Claims Information

While these services are already performed in the initial prenatal visit, additional information is necessary for claims submission. The provider (PCP or OB) providing EPSDT services for members 12-20 years of age, must submit the medical claims for these members. When submitting claims, please include one of the following codes that reflect the appropriate EPSDT visit:

  • Ages 12 through 17 years
    • New patient - 99384
    • Established patient - 99394
  • Ages 18 through 20 years
    • New patient - 99385
    • Established patient - 99395

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9.11 Loss of AHCCCS Coverage During Pregnancy

Members may lose AHCCCS eligibility during pregnancy. Although members are responsible for maintaining their own eligibility, providers are encouraged to notify MCP if they are aware that a pregnant member is about to lose or has lost eligibility. MCP can assist in coordinating or resolving eligibility and enrollment issues so that pregnancy care may continue without a lapse in coverage. Please call Member Services at (602) 263-3000 or (800) 624-3879 to report eligibility changes for pregnant members.

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9.12 Pre-Selection of Newborn's PCP

Prior to the birth of the baby, the mother selects a PCP for the newborn. The newborn is assigned to the pre-selected PCP after delivery. The mother may elect to change the assigned PCP at any time.

CHAPTER 10 - DENTAL AND VISION SERVICES

Dental Services

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10.0 Dental Services Overview

MCP has a comprehensive dental network to serve the needs of MCP members. The contracted network is available on line at www.MercyCarePlan.com, under Find a Provider. Emergency and general dental services are described below and should be provided in accordance with the AHCCCS EPSDT Periodicity Schedule available on the AHCCCS website at: http://azahcccs.gov/shared/Downloads/MedicalPolicyManual/Chap400.pdf along with the guidelines presented below. Providers should include parents or caregivers in all consultations and counseling of members regarding preventive oral health care and the clinical findings.

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10.1 Dental Emergency Services

The following emergency dental services are covered:

  • Treatment for pain, infection, swelling and/or injury
  • Extraction of symptomatic (including pain), infected and non-restorable primary and permanent teeth, as well as retained primary teeth (extractions are limited to teeth which are symptomatic), and
  • General anesthesia, conscious sedation or anxiolysis (minimal sedation, patients respond normally to verbal commands) when local anesthesia is contraindicated or when management of the patient requires it.

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10.2 Additional Information Regarding Dental Services

Members may select a contracted general dentist and receive preventive dental services without a referral, unless such services require prior authorization, as described below. If prior authorization is required, a provider must:

  • Obtain appropriate prior authorization before rendering non-emergency services.
  • Provide an oral health screening as part of an EPSDT screening and refer members for:
    • Appropriate dental services based on needs identified through the screening process.
    • Routine dental care based on the AHCCCS EPSDT Periodicity Schedule.
  • Document evidence of referrals on the EPSDT form.
  • May refer members for a dental assessment at an earlier age if their oral health screening reveals potential carious lesions or other conditions requiring assessment and/or treatment by a dental professional.
  • Should encourage eligible members under the age of 21 (or under age 20 for KidsCare members), to see a dentist regularly.
  • Follow the AHCCCS EPSDT Periodicity Schedule to identify when routine referrals begin.
  • Should encourage members who call for a dental referral to obtain any routine or follow up care and document all referrals in the member's medical record.

In addition to referrals by PCPs referrals, EPSDT members are allowed self-referral to an MCP contracted dentist.

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Covered Dental Benefits - Summary

10.3 Preventive Dental Services

Preventive dental services specified in the AHCCCS Dental Periodicity Schedule are covered benefits and include:

  • Diagnostic services including comprehensive and periodic examinations.
  • MCP covers two oral examinations and two oral prophylaxis and fluoride treatments per member per year (i.e., one every six months plus 1 day apart) for members 12 months through 20 years of age (through 18 years of age for KidsCare members).
  • Radiology services which are screening in nature for diagnosis of dental abnormalities and/or pathology, including panoramic or full-mouth x-rays, supplemental bitewing x-rays, and occlusal or periapical films as needed.
  • Preventive services which include:
    • Oral prophylaxis performed by a dentist or dental hygienist which includes self-care oral hygiene instructions to member, if able, or to the parent/legal guardian.
    • Application of topical fluorides. Use of a prophylaxis paste containing fluoride and fluoride mouth rinses do not meet the AHCCCS standard for fluoride treatment (fluoride treatment in the PCP office is not a covered service).
    • Space maintainers for age appropriate replacement of posterior primary teeth which are lost prematurely and where unerupted, permanent posterior teeth are present.

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10.4 Therapeutic Dental Services

All therapeutic dental services are covered when medically necessary but must be prior authorized by MCP. These services include but are not limited to:

  • Periodontal procedures, scaling/root planing, curettage, gingivectomy, and osseous surgery
  • Crowns: When appropriate, stainless steel crowns may be used for both primary and permanent posterior teeth; composite, prefabricated stainless steel crowns with a resin window or crowns with esthetic coatings should be used for anterior primary teeth, or
  • Precious or cast semi-precious crowns may be used on functional permanent endodontically treated teeth, except third molars, for members who are 18 through 20 years old.
  • Endodontic services including pulp therapy for permanent and primary teeth, except third molars (unless a third molar is functioning in place of a missing molar)
  • Restoration of carious permanent and primary teeth with accepted dental materials other than cast or porcelain restorations unless the member is 18 through 20 years of age and has had endodontic treatment, and
  • Dentures (both complete and partial), when medically necessary and determined to be the primary treatment of choice or an essential part of an overall treatment plan developed by both the PCP and the dentist in consultation with each other.
  • Orthodontic services and orthognathic surgery are covered only when these services are necessary to treat a handicapping malocclusion. Services must be medically necessary and determined to be the primary treatment of choice or an essential part of an overall treatment plan developed by both the PCP and the dentist in consultation with each other.

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10.5 Orthodontic Services

Orthodontic services are not covered when the primary purpose is cosmetic. Examples of conditions that may require orthodonic treatment include the following:

  • Congenital craniofacial or dentofacial malformations requiring reconstructive surgical correction in addition to orthodontic services.
  • Trauma requiring surgical treatment in addition to orthodontic services.
  • Skeletal discrepancy involving maxillary and/or mandibular structures.

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10.6 Covered Services for Eligible Members 21 Years of Age and Over

Routine and emergency dental services are not covered for adults (age 21 and older), unless related to the treatment of a medical condition such as acute pain, infection, or fracture of the jaw. Covered services for adults (age 21 and older) include:

  • Examination of the oral cavity
  • Required radiographs
  • Complex oral surgical procedures - Maxillofacial fractures
  • Appropriate anesthesia
  • Prescription of pain medications and antibiotics
  • Pre-transplant services (Dental prophylaxis, restorations, extractions) - See below
  • Prophylactic extraction of teeth for head/neck/jaw radiation

Other Exceptions to Dental Services

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10.7 Dental Services Not Covered
  • Orthodontic treatment and extraction of non-symptomatic teeth are generally not covered services. This includes 3rd molars.
  • Services or items furnished solely for cosmetic purposes are not covered by Mercy Care Plan.

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10.8 Dental Services Covered Under Certain Criteria
  • Dentures, orthodontics and orthognathic (related to the placement of the jaw) surgery are covered only if they are determined to be medically necessary and the primary treatment of choice or an essential part of an overall treatment plan.
  • Denture repair or reline to maintain serviceability of dentures is a covered benefit.
  • TMJ treatment is limited to the alleviation of symptoms related to Acute, traumatic injuries only.

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10.9 Dental Medical Necessity

Medical necessity is determined by MCP's medical and dental directors. Medical documentation is required and must be submitted directly to MCP for review and prior authorization determination. The Dental Prior Authorization Request Form can be accessed under the Mercy Care Plan/Provider Tools/Forms section of MCP’s website.

Vision Services

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10.10 Vision Overview

MCP covers eye and optometric services provided by qualified eye/optometry professionals within certain limits based on member age and eligibility:

  • Emergency eye care, which meets the definition of an emergency medical condition, is covered for all members.
  • For members who are 21 years of age or older, treatment of medical conditions of the eye, excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses, are covered.
  • Vision examinations and the provision of prescriptive lenses are covered for members under the EPSDT, KidsCare program and for adults when medically necessary following cataract removal.
  • Cataract removal is covered for all eligible members under certain conditions. For more information, visit the AHCCCS website at: www.azahcccs.gov.

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10.11 Coverage for Children (Under Age 21)
  • Medically necessary emergency eye care, vision examinations, prescriptive lenses and treatments for conditions of the eye.
  • PCPs are required to provide initial vision screening in their office as part of the EPSDT program.
  • Members under age 21 with vision screening of 20/60 or greater should be referred to the contracted vision provider for further examination and possible provision of glasses.
  • Replacement of lost or broken glasses is a covered benefit.
  • Contact lenses are not a covered benefit.

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10.12 Nationwide Referral Instructions

Nationwide is MCP's contracted vendor for all vision services, including diabetic retinopathy exams. Members requiring vision services should be referred by the PCP's office to a Nationwide provider listed on MCP's website. The member may call Nationwide directly to schedule an appointment.

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10.13 Coverage for Adults (21 years and older)
  • Emergency care for eye conditions when the eye condition meets the definition of an emergency medical condition; for cataract removal and/or medically necessary vision examinations; and for prescriptive lenses if required following cataract removal.
  • Routine eye exams and glasses are not a covered service for adults.
  • Adults 21 years of age and older should only be referred to Nationwide for the diagnosis and treatment of eye diseases as well.

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10.14 Dental and Vision Community Resources for Adults

AHCCCS benefits do not include routine dental and vision services for adults. However, there are community resources available to help members obtain routine dental and vision care. For more information, call Mercy Care Member Services at (602) 263-3000 or (800) 624-3879 (toll-free), Express Service Code 629.

CHAPTER 11 - CASE MANAGEMENT AND DISEASE MANAGEMENT

11.0 Case Management and Disease Management Overview

MCP has a comprehensive case management program. The Medical Case Management team considers the medical, social and cultural needs of members by targeting, assessing, monitoring and implementing services for members identified as "at risk." Case Management services are available for all eligible members, excluding MCP (acute and DD) members who are identified as "at risk," such as transplant, hemophilia and HIV members, or those who are high-service utilizers, are assigned a case manager.

A wide spectrum of services are available for members, providers and families who need assistance in finding and using appropriate health care and community resources. The MCP Case Management staff:

  • Considers the medical, social and cultural needs of members in targeting, assessing, monitoring and implementing services for members.
  • Provides assistance to members and families in navigating through the complex medical and behavioral health systems.

Please refer to the Clinical Guidelines available on MCP's website at Mercy Care Plan/Provider Tools for treatment protocol related to:

  • Diabetes
  • Asthma
  • Congestive Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Community Acquired Pneumonia (CAP)
  • Major Depressive Disorder in Adults
  • HIV
  • Attention Deficit/Hyperactivity Disorder (ADHD)

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11.1 Referrals

The MCP central intake coordinator accepts referrals from any source. Please call the central intake coordinator at (602) 453-8391 to make a referral. For the most part, the central intake coordinator can respond to questions and resolve the issue during the initial call. However, a case management referral is initiated for members that require more than a single intervention. Case managers will contact the member either by telephone or by letter. The Case Management staff communicates with members, family and the PCP on an ongoing basis while the member's case is open.

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11.2 Case Management MCP Acute and DD

MCP provides case management services to medically complex members. The members are assigned to an RN, LPN or social work case manager who works closely with the PCP and member to coordinate care and services. The case manager also collaborates with community resources, home health services and PCPs to coordinate medical care and assure appropriate access to medical and social services.

Members who meet any of the following criteria and do not fall under other identified categories of case management also will be considered for case management services:

  • High utilizers of services
  • Frequent inpatient readmissions
  • Substance abusers
  • Poor compliance with prescribed medical treatment
  • Experiencing social problems that are impacting medical care
  • Overuse of emergency department
  • Complex care needs

A health assessment will be conducted of each member accepted into case management. A care plan will be developed and the member's compliance with the plan will be monitored. The case manager interacts routinely with the PCP, the member and the member's care giver/family.

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11.3 HIV/AIDS

Early identification and intervention of members with HIV allows the case manager to assist in developing basic services and information to support the member during the disease process. The case manager links the member to community resources that offer various services, including housing, food, counseling, dental services and support groups. The member's cultural needs are continually considered throughout the care coordination process.

The MCP case manager works closely with the PCP, the MCP corporate director of pharmacy, and an MCP medical director to assist in the coordination of the multiple services necessary to manage the member's care. PCPs wishing to provide care to members with HIV/AIDS must provide documentation of training and experience and be approved by the MCP credentialing process. These PCPs must agree to comply with specific treatment protocols and AHCCCS requirements. PCPs may elect to refer the member to an AHCCCS approved HIV specialist for the member's HIV treatment.

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11.4 High Risk OB

Members that have been identified as high-risk obstetrical patients, either for medical or social reasons, are assigned to an OB case manager to try to ensure a good newborn/mother outcome. Please refer to Chapter 9 - Maternity of this Provider Manual for additional information. The case manager may refer the expectant mother to a variety of community resources, including WIC, food banks, childbirth classes, smoking cessation, teen pregnancy case management, shelters and counseling to address substance abuse issues. A case manager monitors the pregnant woman throughout the pregnancy, and provides support and assistance to help reduce risks to the mother and baby.

Case managers also work very closely with the PCP to make sure that the member is following through with all prenatal appointments and the prescribed medical regimen. Members with complex medical needs are also assigned a medical case manager so that all of the member's medical and perinatal care issues are addressed appropriately.

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11.5 Behavioral Health

The Case Management department is available to assist with referrals to RBHA and to help members who are experiencing problems related to behavioral health services. Please refer to Chapter 7 - Behavioral Health of this Provider Manual for additional information.

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11.6 Disease Management

The Disease Management team administers disease management programs intended to enhance the health outcomes of members. Disease management targets members who have illnesses that have been slow to respond to coordinated management strategies in the areas of diabetes, respiratory (COPD, asthma), and cardiac (CHF). The primary goal of disease management is to positively affect the outcome of care for these members through education and support and to prevent exacerbation of the disease, which may lead to unnecessary hospitalization.

The objectives of disease management programs are to:

  • Identify members who would benefit from the specific disease management program.
  • Educate members on their disease, symptoms and effective tools for self-management.
  • Monitor members to encourage/educate about self care, identify complications, assist in coordinating treatments and medications, and encourage continuity and comprehensive care.
  • Provide evidence-based, nationally recognized expert resources for both the member and the provider.
  • Monitor effectiveness of interventions.

The following conditions are specifically included in MCP's Disease Management programs and have associated Clinical Guidelines that are reviewed annually.

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11.7 Asthma

The Asthma Disease Management program offers coordination of care for identified members with primary care physicians, specialists, community agencies, the members' caregivers and/or family. Member education and intervention is targeted to empower and enable compliance with the physician's treatment plan.

Providers play an important role in helping members manage this chronic disease by promoting program goals and strategies, including:

  • Preventing chronic symptoms.
  • Maintaining "normal" pulmonary function.
  • Maintaining normal activity levels.
  • Maintaining appropriate medication ratios.
  • Preventing recurrent exacerbation and minimizing the need for emergency treatment or hospitalizations.
  • Providing optimal pharmacotherapy without adverse effects.
  • Providing education to help members and their families better understand the disease and its prevention/treatment.

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11.8 Chronic Obstructive Pulmonary Disease (COPD)

The COPD Disease Management program is designed to decrease the morbidity and mortality of members with COPD. The goal of the program is to collaborate with providers to improve the quality of care provided to members with COPD, decrease complication rates and utilization costs, and improve the members' health. The objectives of the COPD Disease Management program are to:

  • Identify and stratify members.
  • Provide outreach and disease management interventions.
  • Provide education through program information and community resources.
  • Provide provider education through the COPD guidelines, newsletters and provider profiling.

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11.9 Congestive Heart Failure (CHF)

The CHF Disease Management program is designed to develop a partnership between MCP, the PCP and the member to improve self-management of the disease. The program involves identification of members with CHF and subsequent targeted education and interventions. The CHF Disease Management program educates members with CHF on their disease, providing information on cardiac symptoms, blood pressure management, weight management, nutritional requirements and benefits of smoking cessation.

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11.10 Diabetes

The Diabetes Disease Management program is designed to develop a partnership between MCP, the PCP and the member to improve self-management of the disease. The program involves identification of members with diabetes and subsequent targeted education and interventions. In addition, the program offers providers assistance in increasing member compliance with diabetes care and self-management regimens. Providers play an important role in helping members manage this chronic condition. MCP appreciates providers' efforts in promoting the following program goals and strategies:

  • Referrals for formal diabetes education through available community programs
  • Referrals for annual diabetic retinal eye exams by eye care professionals as defined in MCP's Diabetes Management Practice Guidelines
  • Laboratory exams that include:
    • Glycohemoglobins at least twice annually
    • Micro albumin
    • Fasting lipid profile annually
    • Management of co-morbid conditions like blood pressure, CHF, and blood cholesterol.

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11.11 Active Health

MCP has contracted with Active Health Management to administer a patient health-tracking program that was implemented in October of 2008 with providers. Effective March of 2010, members will be receiving letters concerning their "Care Considerations" as well.

Active Health will expand MCP's opportunities to identify members at risk for poor health outcomes and to communicate directly with the providers who are responsible for their care, in a time-critical mode. It also enables the member to work closely with their physician to choose treatments and tests that are right for them, Active Health utilizes data received through claim, lab and pharmacy submissions to identify potential opportunities to meet evidence based guidelines, such as through the addition of new therapies, avoidance of contraindications or prevention of drug interactions. When an opportunity is identified for our member, a formal patient-specific communication will be sent to the provider to assist in offering health care to the patient based upon the physician's independent medical judgment. A "Care Consideration" letter will be sent to the member as well, encouraging them to discuss the "Care Consideration" with their physician.

It is important to note that this program is not a utilization review mechanism and does not constitute consultation. MCP's goal is to offer timely, accurate and patient-specific information to facilitate patient care and improve outcomes.

Examples of "Care Consideration" are:

  • If the member is a diabetic and there are no records that the patient has had their eyes checked or an HgA1c lab has been done.
  • If the patient has a heart condition and there are no records to show that the member is on any type of drug to lower cholesterol.

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CHAPTER 12 - CONCURRENT REVIEW

12.0 Concurrent Review Overview

MCP conducts concurrent utilization review on each member admitted to an inpatient facility, including skilled nursing facilities and freestanding specialty hospitals. Concurrent review activities include both admission certification and continued stay review. The review of the member's medical record assesses medical necessity for the admission, and appropriateness of the level of care, using the Milliman Care Guidelines® and the AHCCCS NICU/Nursery/Step-Down Utilization Guidelines. Admission certification is conducted within one business day of receiving notification.

Continued stay reviews are conducted before the expiration of the assigned length of stay. Providers will be notified of approval or denial of length of stay. MCP Plan nurses conduct these reviews. The nurses work with the medical directors in reviewing medical record documentation for hospitalized members. MCP medical directors make rounds on site as necessary. MCP concurrent review staff will notify the facility case management department and business office at the end of the member's hospitalization stay, by fax, of the days approved and at what level of care.

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12.1 MILLIMAN Care Guidelines®

MCP uses the Milliman Care Guidelines® to ensure consistency in hospital-based utilization practices. The guidelines span the continuum of patient care and describe best practices for treating common conditions. The Milliman Care Guidelines® are updated regularly as each new version is published. A copy of individual guidelines pertaining to a specific case is available for review upon request.

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12.2 Discharge Planning Coordination

Effective and timely discharge planning and coordination of care are key factors in the appropriate utilization of services and prevention of readmissions. The hospital staff and the attending physician are responsible for developing a discharge plan for the member and for involving the member and family in implementing the plan.

The MCP concurrent review Nurse (CRN) works with the hospital discharge team and attending physicians to ensure that cost-effective and quality services are provided at the appropriate level of care. This may include, but is not limited to:

  • Assuring early discharge planning.
  • Facilitating or attending discharge planning meetings for members with complex and/or multiple discharge needs.
  • Providing hospital staff and attending physician with names of contracted MCP providers (i.e., home health agencies, DME/medical supply companies, other outpatient providers).
  • Informing hospital staff and attending physician of covered benefits as indicated.

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12.3 Physician Medical Review

MCP Plan medical directors conduct medical review for each case with the potential for denial of authorization. The CRN (Inpatient) or the prior authorization nurse (Outpatient) reviews the documentation for evidence of medical necessity according to established criteria. When the criteria are not met, the case is referred to a MCP medical director. The medical director reviews the documentation, discusses the case with the nurse and may call the attending or referring physician for more information. The requesting physician may be asked to submit additional information. Based on the discussion with the physician or additional documentation submitted, the medical director will decide to approve, deny, modify, reduce, suspend or terminate an existing or pending service.

Utilization management decisions are based only upon appropriateness of care and service. MCP does not reward practitioners, or other individuals involved in utilization review, for issuing denials of coverage or service. The decision to deny a service request will only be made by a physician.

For inpatient denials, the attending physician and hospital staff are verbally notified when MCP is stopping payment. The hospital will receive written notification with the effective date of termination of payment or reduction in level of care. The attending or referring physician may dispute the finding of the medical director informally by phone or formally in writing. If the finding of the medical director is disputed, a formal appeal may be filed according to the established MCP appeals process.

CHAPTER 13 - PHARMACY MANAGEMENT

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13.0 Pharmacy Management Overview

Prescription drugs may be prescribed by any authorized provider, such as a PCP, attending physician, dentist, etc. Prescriptions should be written to allow generic substitution whenever possible and signatures on prescriptions must be legible in order for the prescription to be dispensed. The Preferred Drug List (PDL), also referred to as a Formulary, identifies the medications selected by the Pharmacy and Therapeutics Committee (P&T Committee) that are clinically appropriate to meet the therapeutic needs of our members in a cost effective manner.

  • MCP PDLs may also be downloaded to mobile devices (e.g. Blackberry, Palm, Windows Mobile and iPhone) by going to www.epocrates.com.

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13.1 Updating the Preferred Drug Lists (PDLs)

MCP PDLs are developed, monitored and updated by the P&T Committee. The P&T Committee continuously reviews the PDLs and medications are added or removed based on objective, clinical and scientific data. Considerations include efficacy, side effect profile, and cost and benefit comparisons to alternative agents, if available.

Key considerations:

  • Therapeutic advantages outweigh cost considerations in all decisions to change PDLs. Market share shifts, price increases, generic availability and varied dosage regimens may affect the actual cost of therapy.
  • Products are not added to the list if there are less expensive, similar products on the formulary.
  • When a drug is added to the PDL, other medications may be deleted.
  • Participating physicians may request additions or deletions for consideration by the P&T Committee. Requests should include:
    • Basic product information, indications for use, its therapeutic advantage over medications currently on the PDL.
    • Which drug(s), if any, the recommended medication would replace in the current PDL.
    • Any published supporting literature from peer reviewed medical journals.

MCP may invite the requesting physician to the P&T Committee to support the addition to the PDL and answer related questions. However, MCP does not permit pharmaceutical representatives to participate or attend P&T Committee meetings. All PDL requested additions should be sent to:

Schaller Anderson, an Aetna Company
Corporate Director of Pharmacy
4645 E. Cotton Center Blvd.
Building 1, Suite 200
Phoenix, AZ 85040

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13.2 Notification of PDL Updates

MCP will not remove a medication from the PDL without first notifying providers and affected members. MCP will provide at least 60 days notice of such changes. MCP is not required to send a hard copy of the PDL each time it is updated, unless requested. A memo may be used to notify providers of updates and changes and may refer providers to view the updated PDL on the MCP website. MCP may also notify providers of changes to the PDL via direct letter. MCP will notify members of updates to the PDL via direct mail and by notifying the prescribing provider, if applicable.

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13.3 Prior Authorization Required

Prior authorization is required:

  • If the drug is not included on the PDL.
  • If the prescription requires compounding.
  • For injectable medications dispensed by a pharmacy, with the exception of heparin and insulin. Note: If the member has a primary insurance that reimburses for injectable medications, MCP will only coordinate benefits as the secondary payer if the MCP pharmacy prior authorization process was followed.
  • For medication quantities which exceed recommended doses.
  • For specialty drugs which require certain established clinical guidelines be met before consideration for prior authorization.
  • For certain medications that may require additional documentation, e.g. Peg-Intron.

Allow up to 14 calendar days for the prior authorization review process. In instances where a prescription is written for drugs not on the PDL, the pharmacy may contact the prescriber to either request a PDL alternative or to advise the prescriber that prior authorization is required for non-PDL drugs.

Complete Coverage Determination Request Form and fax to (800) 854-7614. All forms must be complete and legible or the request may be delayed while additional information, documentation or clarification is requested. This form is available at Mercy Care Plan/Provider Tools/Forms section on the MCP website.

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13.4 Over The Counter (OTC) Medications

A limited number of OTC medications are covered for MCP members. OTC medications require a written prescription from the physician that must include the quantity to be dispensed and dosing instructions. Members may present the prescription at any MCP contracted pharmacy. OTCs are limited to the package size closest to a 30-day supply. Some medications may require step therapy. Please refer to the Provider Drug List for more information.

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13.5 Generic vs. Brand

Generic medications represent a considerable cost savings to the health care industry and Medicaid program. As a result, generic substitution with A-rated products is mandatory unless the brand has been specifically authorized or as otherwise noted. Medications on the PDL noted with an asterisk (*) will be filled with the brand name only, even when a generic form is available. In all other cases, brand names are listed for reference only.

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13.6 Diabetic Supplies

Diabetic supplies are limited to a one-month supply (to the nearest package size) with a prescription.

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13.7 Injectable Drugs

The following types of injectable drugs are covered when dispensed by a licensed pharmacist or administered by a participating provider in an outpatient setting:

  • Immunizations
  • Chemotherapy for the treatment of cancer
  • Medication to support chemotherapy for the treatment of cancer
  • Glucagon emergency kit
  • Insulin; Insulin syringes
  • Immunosuppressant drugs for the post-operative management of covered transplant services
  • Rhogam
  • Rabies vaccine

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13.8 Exclusions

The following items, by way of example, are not reimbursable by MCP:

  • Anorexiants
  • DESI drugs (those considered less than effective by the FDA)
  • Non-FDA approved agents
  • Rogaine
  • Any medication limited by federal law to investigational use only
  • Medications used for cosmetic purposes
  • Non-indicated uses of FDA approved medications without prior approval by MCP
  • Lifestyle medications (such as medications for erectile dysfunction)
  • Medications used for fertility

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13.9 Family Planning Medications and Supplies

Schaller Anderson, an Aetna Company, administers the family planning benefit for MCP. Please refer to www.schalleranderson.com for family planning medications and supplies.

  • Over-the-counter items related to family planning (condoms, foams, suppositories, etc.) are covered and do not require prior authorization. However, the member must present a written prescription, to the pharmacy including the quantity to be dispensed. A supply for up to 30-days is covered.
  • Injectable medications, administered in the provider's office, such as Depo-Provera will be reimbursed at the MCP Fee Schedule, unless otherwise stated in the provider's contract.
  • Oral contraceptives are covered for MCP members, through Schaller Anderson (SA).

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13.10 Behavioral Health Treatment of ADHD, Anxiety, Depression and Post Partum Depression

For Acute and DD members, behavioral health benefits, including antipsychotics, are covered by the RBHA and provided by RBHA contracted pharmacies.

Please refer to Chapter 7 - Behavioral Health in this Provider Manual for additional information. PCPs must use the AHCCCS clinical guidelines for the treatment and prescribing of medications for ADHD, Anxiety and Depression. The clinical guidelines are available at: www.azahcccs.gov

PCPs may prescribe behavioral health medications to treat selected behavioral health disorders for MCP acute and DD members. These include ADD/ADHD, mild depression or anxiety disorder. Behavioral health must be:

  • Included on the MCP PDL.
  • Limited to a 30-day supply.
  • Prescribed in generic forms and will be substituted with generic as they become available unless otherwise designated.

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13.11 RBHA Covered Services Medication Management Program

Close communication between PCP's and RBHA prescribers must occur to prevent duplicate filling of prescriptions by both the RBHA and MCP. PCPs may treat members for ADHD, anxiety, depression or post partum depression. If the PCP believes the member's condition is beyond his/her area of expertise or the member fails to respond to treatment, the member must be referred to the RBHA for ongoing treatment, medication management and prescriptions. Members who are enrolled with the RBHA must be referred to a RBHA contracted pharmacy to have their prescriptions filled. For a list of RBHA contracted pharmacies refer to the website of the RBHA in your county.

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13.12 Pharmacy Forms

Non-formulary requests can be submitted by using the Coverage Determination Request Form Specialty medication can be requested by using the Specialty Medication Authorization Form. Pharmacy Prior Authorization Guidelines can also be accessed from the MCP website. Both forms are available on the Mercy Care Plan/Provider Tools/Forms section of the MCP website.

CHAPTER 14 - QUALITY MANAGEMENT

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14.0 Quality Management Overview

MCP works in partnership with providers to continuously improve the care given to our members. The MCP Quality Management (QM) Department is comprised of the following areas:

  • The Quality of Care Review unit monitors the quality of care provided by the PHP network, as well as the review and resolution of issues related to the quality of health care services provided to members.
  • The Prevention and Wellness unit is responsible for quality improvement activities and clinical studies using data collected from providers and encounters. Findings are reported to AHCCCS and to providers about their performance on specific quality indicators.
  • The Credentialing unit is responsible for provider credentialing/recredentialing activities.
  • The Special Needs unit is responsible for coordination and liaison with the programs for CRS clinics located in four regions of the state, and for Acute Care behavioral health services provided statewide by the RBHA's. In addition, the unit works to coordinate Acute Care health services for MCP and DD members.

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14.1 Quality Management Department Responsibilities

The QM department is responsible for development of Clinical Guidelines and policies related to quality management. Whenever possible, MCP adopts Clinical Guidelines from national organizations known for their expertise in the area of concern. Clinical Guidelines are available at the MCP web site. Providers may also request copies from the QM department or their Provider Relations representative.

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14.2 Quality Management Plan

A quality management plan is developed each year to guide the efforts of the MCP Quality Management (QM) department in accomplishing its goals for the upcoming year. The QM Department works closely with the chief medical officer (CMO) and the MCP medical directors on all QM responsibilities. For more information about the MCP Quality Management program, or to obtain a written summary of the program, please contact your Provider Relations representative or call the QM Department at (602) 263-3000 or (800) 624-3879.

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14.3 Quality of Care, Peer Review and Fair Hearing Process

The QM department reviews potential quality of care (QOC) issues referred by internal and external sources. Applicable medical records are requested from providers as needed for review. The QOC, peer review and fair hearing processes are all confidential. Each QOC issue is assigned a severity level based on potential adverse effect(s) for the member. In addition, cases are trended and reported to the QM/UM Committee. QOC Severity Levels are as follows:

  • Level 0 - No quality of care or utilization issue exists and no action is needed.
  • Level 1 - Potential for significant adverse effect(s) on the member was not found, no harm or negative outcome occurred, and the risk of further problems is low.
  • Level 2 - Potential for significant adverse effect(s) was evident. Because of the care received or services provided, or because of the omission of care or services, the member required a change in the plan of care or suffered a complication, which caused no major life impact.
  • Level 3 - Medical management resulted in significant adverse effect(s). Because of the care received or services provided, or omission of care or services, the member suffered a major complication or poor outcome.

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14.4 Escalation Process

All potential QOC issues involving health professionals are forwarded to the CMO or one of the MCP medical directors for review. After review, it may be determined that a case should be referred to a specialist for further review. The case is sent to the medical care ombudsman. Program is sent for review by a provider in the same specialty as the subject provider.

If indicated by the evaluation conducted by the MCP medical director or specialist review, the QOC case is forwarded to the Executive Session of the QM/Utilization Review (UM) Committee for peer review discussion, final determination and recommendation for action. Health professionals have the right to appeal adverse actions such as termination from MCP.

To exercise this option, the appeal process for a fair hearing must be followed. A copy of the peer review/fair hearing policy is available to all providers upon request.

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14.5 Ambulatory Medical Record Review

The purpose of the review is to verify that medical records of contracted family practice, internal medicine, and general practice, obstetric and pediatric physicians comply with established AHCCCS, NCQA, and MCP medical record keeping standards. Reviews are completed every three years. In addition, OB/GYN specialists must comply with ACOG standards. Records are reviewed for completeness of documentation, coordination of care and evidence of appropriate health maintenance screenings. QM nurses review the medical records at the physician's office. The steps for conducting a medical records review include:

  • Approximately two weeks before a review is scheduled, the office is contacted by telephone to arrange a mutually convenient time for the review.
  • A letter or fax is sent further stating when the QM staff will arrive, and which member records should be pulled and ready for review.
  • The number of nurses assigned is based on the number of records to be reviewed. The review team will need a private area where they can work.
  • A report will be created following the visit. The report will identify trends that were noted, as well as any significant areas that need follow up.
  • The report will be sent to the physician's office after the review is completed.
  • Physicians with a low score may be asked to provide a quality improvement plan detailing methods to improve future service delivery and documentation. Follow-up medical record reviews will be conducted as needed.

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14.6 Quality Management Studies

MCP uses a variety of information sources to conduct quality management studies, including member medical records, claims, prior authorization logs, statistical reports and utilization review reports. As part of the quality improvement process, MCP asks its provider network to assist in the collection of medical record information or other information as needed for special studies or reviews. The QM department is managing the following annual clinical studies.

  • Improving the rate of hemoglobin A1c (HbA1c) testing among members with diabetes:
  • Improving the provider submission of immunization data to ASIIS
  • Asthma Management Project
  • Adolescent access to care

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14.7 Data Collection and Reporting

The QM Department collects data and analyzes MCP performance for the following indicators:

  • Well-child visits in the first 15 months of life
  • EPSDT participation rates
  • Childhood immunization (for members 24 months old)
  • Adolescent immunization
  • Annual dental visits for members age 1-20
  • Children's access to primary care providers
  • Adolescent well-care visits
  • Cervical cancer screening
  • Adult access to preventive/ambulatory health services
  • Mammograms (for women between the ages of 42 - 69 years of age)
  • Diabetes management
  • Appropriate Asthma medication
  • Chlamydia screening
  • Prenatal care
  • Postpartum services

Clinical indicators are reviewed regularly to monitor progress. Findings and results of studies and surveys are shared with health professionals via newsletters.

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14.8 Reports

The QM department has developed reports for health professionals on the following topics:

  • Mammograms: A monthly report of members who are in need of a mammogram.
  • Diabetes: A quarterly report of members diagnosed with diabetes and diabetes-related services rendered during the past 12 months.
  • Asthma: A quarterly report of members diagnosed with asthma and their health professional's prescribing patterns to treat the member's asthma.
  • Immunizations: A monthly report listing members due for one or more immunizations.
  • Well Child: A monthly report listing members due for a Well Child visit.
  • Cervical Cancer Screening: A monthly report of members who are due for a pap smear.

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14.9 Credentialing/Re-Credentialing

The Credentialing Committee (comprised of both network peer physicians and MCP medical directors) reviews all credentialing information and forwards their recommendations to the CMO who presents the information to the Quality Management Oversight Committee and the MCP Board of Directors for a final decision. Providers have the following rights:

  • To review their application and information obtained from outside sources, (e.g. state licensing agencies and malpractice carriers) with the exception of references, recommendations or other peer-review protected information.
  • To correct erroneous information submitted by another source. MCP will notify credentialing applicants if information obtained from other sources (e.g. licensure boards, National Practitioner Data Bank, etc.) varies substantially from that provided by the applicant.

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14.10 Streamlining Process

MCP is dedicated to improving and streamlining credentialing processes and timelines for those providers credentialed and re-credentialed directly through MCP. In addition, contractual relationships have been developed to delegate credentialing and re-credentialing activities to approved, qualified outside entities throughout the state. This practice has been put into place to decrease the time spent completing multiple credentialing applications for providers belonging to one of these entities, and to ensure a complete and comprehensive network for MCP members.

Providers' credentialed/re-credentialed through a delegated entity must still be approved through the MCP Board of Directors prior to providing health care services to members. Providers are re-credentialed every three years and must complete the required reappointment application. Updates of malpractice coverage, state licenses and Drug Enforcement Agency (DEA) certificates, if applicable, are also required. The MCP Special Needs Unit (SNU) coordinates care and services with the carve-out programs for MCP members enrolled in one or more of the following programs:

  • AZ Department of Health Services (ADHS), Division of Behavioral Health Services (DBHS)
  • ADHS Division of Children's Rehabilitation Services (CRS) and
  • AZ Department of Economic Security, Division of Developmental Disabilities.

MCP performs the following activities:

  • Assists in resolving coordination of benefit issues.
  • Monitors timeliness of services delivered by MCP providers.
  • Provides information or clarification to parents/guardians and providers.
  • Ensures services are provided by the appropriate resource - either MCP or the carveout program.
  • Serve as the MCP liaison for the state agencies listed above, and their contractors for CRS, behavioral health and DD services.

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14.11 CRS Eligible Members

MCP coordinates benefits between network providers and the CRS clinics or private insurance carriers; assisting the parents/guardians of members with the CRS enrollment process; follow up to ensure members receive necessary services; and consulting with MCP departments about services that should be covered by CRS and those that are MCP's responsibility.

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14.12 Behavioral Health

MCP activities include overseeing referrals to the RBHA for behavioral health screenings, evaluations and treatment; coordination of benefits with the statewide RBHA system; consultation with MCP departments regarding MCP Acute members with behavioral disorders; and serving as the contact for selected members with a behavioral health disorder.

For members with a developmental disability, activities include coordination of benefits with DES/DDD and private insurance carriers; consultation with other MCP departments to ensure that they receive medically necessary services; monitoring the timeliness of service delivery; providing information to members and their parents/guardians and providers; and coordinating with DES/DDD support managers regarding long term care and other services that members are also entitled to receive.

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CHAPTER 15 - REFERRALS AND AUTHORIZATIONS

15.0 Referral Overview

It may be necessary for a MCP member to be referred to another provider for medically necessary services that are beyond the scope of the member's PCP. For those services that do not require prior authorization, providers only need to complete the Referral Form and refer the member to the appropriate MCP PHP. MCP's website includes a provider search function for your convenience. More information is available in this Provider Manual under section 4.35 MercyOneSource concerning referrals.

There are two types of referrals:

  • Participating providers (particularly the member's PCP) may refer members for specific covered services to other practitioners or medical specialists, allied healthcare professionals, medical facilities, or ancillary service providers.
  • Member may self-refer to certain medical specialists for specific services such as an OB/GYN.

Referrals must meet the following conditions:

  • The referral must be requested by a participating provider and be in accordance with the requirements of the member's benefit plan (covered benefit).
  • The member must be enrolled in MCP on the date of service (s) and eligible to receive the service.

If MCP's network does not have a PHP to perform the requested services, members may be referred to out of network providers if:

  • The services required are not available within the MCP network.
  • MCP prior authorizes the services.

If out of network services are not prior authorized, the referring and servicing providers may be responsible for the cost of the service. The member may not be billed if the provider fails to follow MCP's policies. Both referring and receiving providers must comply with MCP policies, documents, and requirements that govern referrals (paper or electronic) including prior authorization. Failure to comply may result in delay in care for the member, a delay or denial of reimbursement or costs associated with the referral being changed to the referring provider.

Referrals are a means of communication between two providers servicing the same member. Although MCP encourages the use of its referral form, it is recognized that some providers use telephone calls and other types of communication to coordinate the member's medical care. This is acceptable to MCP as long as the communication between providers is documented and maintained in the members' medical records.

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15.1 Referring Provider's Responsibilities
  • Confirm that the required service is covered under the member's benefit plan prior to referring the member.
  • Confirm that the receiving provider is contracted with MCP.
  • Obtain prior authorization for services that require prior authorization or are performed by a non-PHP.
  • Complete a Referral Form and mail or fax the referral to the receiving provider.

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15.2 Receiving Provider's Responsibilities

PHPs may render services to members for services that do not require prior authorization and that the provider has received a completed MCP referral form (or has documented the referral in the member's medical record). The provider rendering services based on the referral is responsible to:

  • Schedule and deliver the medically necessary services in compliance with MCP's requirements and standards related to appointment availability.
  • Verify the member's enrollment and eligibility for the date of service. If the member is not enrolled with MCP on the date of service, MCP will not render payment regardless of referral or prior authorization status.
  • Verify that the service is covered under the member's benefit plan.
  • Verify that the prior authorization has been obtained, if applicable, and includes the prior authorization number on the claim when submitted for payment.
  • Obtain prior authorization for any ancillary services or tests, procedures, or treatments provided beyond the initial consultation and two follow-up visits (unless specifically exempted by contract or other policy).
  • Inform the referring provider of the consultation or service by sending a report and applicable medical records to allow the referring provider to continue the member's care.

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15.3 Period of Referral

Unless otherwise stated in a PHP's contract or MCP documents, a referral is valid for three visits or sixty (60) days from the date it is signed and dated by the referring provider (if paper), as long as the member is enrolled and eligible with MCP on the date of service. Exceptions to this process are:

  • When medically necessary, MCP may consider exceptions to the three week or sixty day requirement on a case by case basis.
  • Referrals for hematology/oncology continuing care, oncology radiation, and orthopedic continuing care (valid for 120 days).
  • Referrals for obstetrical services (valid through delivery or termination of pregnancy plus 90 days of postpartum care).

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15.4 Maternity Referrals

Referrals to Maternity Care Health Practitioners may occur in two ways:

  • A pregnant MCP member may self-refer to any MCP contracted Maternity Care Practitioner.
  • The PCP may refer pregnant members to a MCP contracted Maternity Care Practitioner.

At a minimum, Maternity Care Practitioners must adhere to the following guidelines:

  • Coordinate the members maternity care needs until completion of the postpartum visits.
  • Schedule a minimum of one postpartum visit at approximately six weeks postpartum.
  • When necessary, refer members to other practitioners in accordance with the MCP referral policies and procedures.
  • Schedule return visits for members with uncomplicated pregnancies consistent with the American College of Obstetrics and Gynecology standards:
  • Through twenty-eight weeks of gestation - every four weeks
  • Between twenty-nine and thirty six weeks gestation every two weeks
  • After the thirty sixth week - once a week
  • Schedule first-time appointments within the required time frames
  • Members in first trimester - within seven calendar days
  • Members in third trimester - within three calendar days
  • High-risk Members - within three calendar days of identification or immediately when an emergency condition exists.

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15.5 Ancillary Referrals

All practitioners and providers must use and/or refer to MCP contracted ancillary providers.

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15.6 Member Self-Referrals

MCP members are allowed to self-refer to participating providers for the following covered services:

  • Family planning services.
  • Women's routine and preventive health care services i.e., pap smears and mammograms provided by a women's health specialist within the MCP network.
  • Dental services.

When a member self refers for any of the above services, providers rendering services must adhere to the same referral requirements as described above.

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15.7 Prior Authorization

MCP requires prior authorization for selected acute outpatient services and planned hospital admissions. Prior authorization is not required for emergency services. Prior authorization guidelines are reviewed and updated regularly. If you have questions about requirements, please refer to Prior Authorization and Outpatient Prior Authorization Changes available on the MCP website or contact your Provider Relations representative. More information is available in this Provider Manual under section 4.35 MercyOneSource concerning authorizations. You may also call our Prior Authorization department at (602) 263-3000 or (800) 624-3879 (toll-free) and dial Express Service Code 622.

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15.8 Special Requirements

Not all specialty services require prior authorization. In some cases, only a referral is necessary to initiate specialty services, as indicated in the Referral section.

Authorization is required for the following provider types and services:

  • Allergist - for members 21 and over
  • Anesthesiologist, for pain management
  • Geneticist
  • Obstetrician services
  • Plastic surgeon
  • Non-Participating Health Providers (PHP)s and specialists

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15.9 Types of Requests
  • Urgent Request: Request is appropriate for a non-life threatening condition, which if not treated promptly, will result in a worsened or more complicated patient condition. An urgent request will be responded to within 3 working days upon receipt. MCP may change an urgent request to a routine request if the urgent request does not meet criteria for urgent status. The member and provider will be notified if the status changes and be provided with the new timeframes to process the request.
  • Routine Request: Request will be responded to within a maximum of fourteen (14) calendar days upon receipt of request.

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15.10 Medical Prior Authorizations

Medical Prior Authorization team is responsible for processing prior authorization request for nonemergency, elective procedures and services.

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15.11 Pharmacy Prior Authorization

The Pharmacy Prior Authorization team is responsible for processing prior authorization requests for the following:

  • Medications not included in the MCP's PDL, also referred to as a formulary.
  • Medications that require prior authorization.
  • Step Therapy medications.
  • Medications with Quantity Limits.

A team of registered pharmacists and certified pharmacy technicians authorize based on a set of pre-established clinical guidelines. Refer to Chapter 13 - Pharmacy Management in this Provider Manual for additional information.

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15.12 Dental Prior Authorizations

The Dental Prior Authorization team is responsible for receiving, reviewing, documenting and issuing dental authorization for covered services. Refer to Chapter 10 - Dental and Vision Services for additional information.

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15.13 Extensions and Denials

If MCP requires additional clinical documentation to make a decision on the prior authorization request, MCP will extend the turnaround time for an additional fourteen (14) calendar days. MCP will notify the provider and member of this extension and detail the request for additional documentation. If the requested supporting documentation is not received within the requested timeframe, MCP may deny the request for prior authorization on the date that the timeframe expires.

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15.14 Prior Authorization and Referrals for Services
  • Laboratory Services and Referrals: Prior authorization is NOT required for approved in office lab procedures that are CLIA certified. MCP is contracted with Sonora Quest to provide laboratory services. For a listing of CLIA waived laboratory services, please reference Laboratory Services Network and CLIA Waived In Office Lab Codes Effective 061511 under the Mercy Care Plan/Provider Tools/Provider Notifications on the MCP website.
  • Radiology Services Referrals: Prior authorization IS required before referring members for certain radiology services. The prior authorization summary on the MCP website contains additional information on services that require prior authorization: Please access the Outpatient Prior authorization Changes under Mercy Care Long Term Care/Prior Authorization for additional information.
  • Infusion or Enteral Therapy Referrals: Prior authorization is NOT required to refer members to a contracted infusion or enteral provider. However, any medically necessary services rendered by an infusion or enteral provider must be prior authorized.
  • Durable Medical Equipment (DME) Referrals: Prior authorization is NOT required to refer members to a contracted DME provider. However, certain services may require prior authorization, as indicated in the provider's contract.
  • DES/DDD Prior Authorization: Prior authorization IS required. Providers must also obtain prior authorization from the DES/DDD medical director prior to provide sterilization and pregnancy termination procedures for members enrolled with DES/DDD.

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15.15 Prior Authorization and Coordination of Benefits

If other insurance is the primary payer before MCP, prior authorization of a service is not required, unless it is known that the service provided is not covered by the primary payer. If the service is not covered by the primary payer, the provider must follow MCP’s prior authorization rules.

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15.16 Prior Authorization Contacts

Inpatient Hospital and Hospice Services
Fax: (602) 431-7363
(866) 300-3926 (Toll Free)

Pharmacy Prior Authorization
Fax: (800) 854-7614 (Toll Free)

Behavioral Health Department
(For Acute and DD members)
Mercy Care Behavioral Health Coordinator (BHC).
Fax: (602) 414.7669

The BHC serves as liaison between members, the Plan and RBHA.

CHAPTER 16 - BILLING, ENCOUNTERS AND CLAIMS

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16.0 Billing Encounters and Claims Overview

The MCP Claims department is responsible for claims adjudication, resubmissions, claims inquiry/research and provider encounter submissions to AHCCCS.

All providers who participate with MCP must first register with AHCCCS to obtain an AHCCCS Provider Identification Number. Please contact AHCCCS directly for this number. Once you have obtained your 6 digit AHCCCS provider ID, notify Provider Relations.

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BILLING

16.1 When to Bill a Member

A member may be billed when the member knowingly receives non-covered services.

  • Provider MUST notify the member in advance of the charges.
  • Provider should have the member sign a statement agreeing to pay for the services and place the document in the member's medical record.

MCP members may NOT be billed for covered services or for services not reimbursed due to the failure of the provider to comply with MCP's prior authorization or billing requirements. Please refer to Arizona Revised Statute A.R.S. §36-2903.01 (L) and Administrative Codes R9-22-702, R9-27-702, R9-28-702, R9-30-702 I and R9-31-702 for additional information. In particular, Arizona Administrative Code R9-22-702 states in part, "an AHCCCS registered provider shall not do either of the following, unless services are not covered or without first receiving verification from the Administration [AHCCCS] that the person was not an eligible person on the date of service:

  1. Charge, submit a claim to, or demand or collect payment from a person claiming to be AHCCCS eligible; or
  2. Refer or report a person claiming to be an eligible person to a collection agency or credit reporting agency"

MCP members should not be billed, or reported to a collection agency for any covered service your office provides.

Provider may NOT collect copayments, coinsurance or deductibles from members with other insurance, whether it is Medicare, a Medicare HMO or a commercial carrier. Providers must bill MCP for these amounts and MCP will coordinate benefits. Unless otherwise stated in contract, MCP adjudicates payment using the lesser of methodology and members may not be billed for any remaining balances due to the lesser of methodology calculation.

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16.2 Prior Period Coverage

On occasion, AHCCCS eligible members are enrolled retrospectively into MCP. The retrospective enrollment is referred to a Prior Period Coverage (PPC). Members may have received services during PPC and MCP is responsible for payment of covered services that were received.

For services rendered to the member during PPC, the provider must submit PPC claims to MCP for payment of covered benefits. The provider must promptly refund, in full, any payments made by the member for covered services during the PPC period.

While prior authorization is not required for PPC services, MCP may, at its discretion, retroactively review medical records to determine medical necessity. If such services are deemed not medically necessary, MCP reserves the right to recoup payment, in full, from the provider. The provider may not bill the member.

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ENCOUNTERS

16.3 Encounter Overview

An encounter is a record of an episode of care indicating medically necessary services provided to an enrolled member. To comply with federal reporting requirements, AHCCCS requires the submission of claims and encounters for all services provided to enrolled members. Fines and penalties are levied against MCP for failure to correctly report encounters in a timely manner. MCP may pass along these financial sanctions to a provider that fails to comply with encounter submissions.

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16.4 When to File an Encounter

Encounters should be filed for all services provided, even those that are capitated. MCP uses the encounter information to determine if care requirements have been met and establish rate adjustments.

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16.5 How to File an Encounter

In order to comply with federal reporting requirements, the AHCCCS Administration conducts data validation studies on a random sample of members' medical records to compare recorded utilization information with submitted encounter data. The study evaluates the correctness or omission of encounter data. It is imperative that claims and encounters are submitted with correct procedure and diagnosis coding, and that the codes entered on the claim correspond to the actual services provided as evidenced in the member's medical record.

Services rendered must also coincide with the category of service listed on the provider record with AHCCCS. If services do not coincide, claims will be reversed and monies recouped. If providers do not properly report all encounters, MCP may be assessed monetary penalties for noncompliance with encounter submission standards. We may then pass these financial sanctions on to providers, or terminate contracts with providers who are not complying with these standards.

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CLAIMS

16.6 When to File a Claim

All claims and encounters must be reported to MCP, including prepaid services.

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16.7 Timely Filing of Claim Submissions

In accordance with contractual obligations, claims for services provided to a MCP member must be received in a timely manner. MCP's timely filing limitations are as follows:

  • New Claim Submissions - Claims must be filed on a valid claim form within 180 days (6 months) from the date services were performed, performed or from the date of eligibility posting, whichever is later, unless there is a contractual exception. For hospital inpatient claims, date of service means the date of discharge of the patient.
  • Other Claim Submissions - Claims must be filed on a valid claim form within 180 days (6 months) from the date services were performed, performed or from the date of eligibility posting, whichever is later, unless there is a contractual exception. For hospital inpatient claims, date of service means the date of discharge of the patient.
  • Claim Resubmission - Claim resubmissions must be filed within 365 days (1 year) from the date of provision of the covered service. If a provider disagrees with resubmission outcome or recoupment of a claim, the provider must submit the claim for resubmission within 60 days of the decision to pay, deny or recoup the claim. Please submit any additional documentation that may effectuate a different outcome or decision.

Failure to submit claims and encounter data within the prescribed time period may result in payment delay and/or denial.

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16.8 MCP as Secondary Insurer

MCP is the payer of last resort. It is critical that you identify any other available insurance coverage for the patient and bill the other insurance as primary. For example, if Medicare is primary and MCP is secondary.

  • Upon the receipt of payment or denial by the other insurer, you should then submit your claim to MCP, showing the other insurer payment amount or denial reason, if applicable, and enclosing a complete legible copy of the remittance advice or Explanation Of Benefits (EOB) from the other insurer.
  • When a member has other health insurance, such as Medicare, a Medicare HMO or a commercial carrier, MCP will coordinate payment of benefits.
  • In accordance with requirements of the Balanced Budget Act of 1997, MCP will pay co-payments, deductibles and/or coinsurance for AHCCCS Covered Services up to the lower of either MCP's fee schedule or the Medicare/other insurance allowed amount.
  • File an initial claim with MCP if you have not received payment or denial from the other insurer before the expiration of your required filing limit. Claims should be submitted within 60 days from the printed date on the notice of disposition (EOB or remittance) from the primary insurer. In all instances, a clean claim must be received by MCP within 12 months of the date of service.

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16.9 Dual Eligibility MCP Advantage Cost Sharing and Coordination of Benefits

For MCA members enrolled in both MCP and MCA, any cost sharing responsibilities will be coordinated between the two payers. For the most part, providers only need to submit one claim to Mercy Care Plan and Mercy Care Advantage and benefits will be automatically coordinated. There may be exceptions to this, which are covered in this chapter under the section titled Instruction for Specific Claim Types.

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16.10 Mercy Healthcare Group (MHG) Coordination of Benefits

Arizona Administrative Code (AAC) R9-27-801 defines the priority of benefit payment for MHG. MHG will coordinate benefits with all third party payers according to AAC R9-27-801. Services provided under MHG are not intended to duplicate other services and benefits available to an employee member.

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16.11 Injuries due to an Accident

In the event the member is being treated for injuries suffered in an accident, the date of the accident should be included on the claim in order for MCP to investigate the possibility of recovery from any third-party liability source. This is particularly important in cases involving work-related injuries or injuries sustained as the result of a motor vehicle accident.

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16.12 How to File a Claim
  1. Select the appropriate claim form (refer to table below).

    16.12a - Claim Form Table

    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 web site addresses:

  2. Complete the claim form.
    • 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.
    • 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.
    • Electronic Clearing House

      Providers who are contracted with MCP 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.

      Additional information can be attained by accessing the Mercy Care Plan/Provider Tools/Provider Notification titled Electronic Submission of Claims/Electronic Fund Transfer/Electronic Remittance Advice.

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

    • Through the Mail
      16.12b Claim Address Table
      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
      Refunds

      Mercy Care Plan
      Attention: Finance Department P.O. Box 52089
      Phoenix, AZ 85072-2089

      		Not applicable.

      *See individual sections for further information: 16.20 Claim Resubmission or Reconsideration and 17.1 Provider Claim Disputes.

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16.13 Correct Coding Initiative

MCP and AHCCCS follow the same standards as MedicareÕs Correct Coding Initiative (CCI) policy and performs CCI edits and audits on claims for the same provider, same recipient, and same date of service. For more information on this initiative, review AHCCCS Medical Policy Manual (Chapter 800) by visiting: http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

MCP utilizes ClaimCheck as our comprehensive code auditing solution that will assist payors with proper reimbursement. Correct Coding Initiative guidelines will be followed in accordance with both AHCCCS and CMS. Additional information will be released shortly regarding provider access to our unbundling software through Clear Claim Connection.

Clear Claim Connection is a web-based stand-alone code auding reference tool designed to mirror MCP's comprehensive code auditing solution through ClaimCheck. It enables MCP to share with our providers the claim auditing rules and clinical rationale inherent in ClaimCheck.

Providers will have access to Clear Claim Connection through MCP's website through a secure login. Clear Claim Connection coding combinations can be used to review claim outcomes after a claim has been processed. Coding combinations may also be reviewed prior to submission of a claim so that the provider can view claim auditing rules and clinical rationale prior to submission of claims.

Further detail on how to use Clear Claim Connection can be accessed at MCP’s website under Mercy Care Plan/Provider Tools/Provider Notifications, titled Clear Claim Connection Provider Web Navigation Guide.

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16.14 Correct Coding

Correct coding means billing for a group of procedures with the appropriate comprehensive code. All services that are integral to a procedure are considered bundled into that procedure as components of the comprehensive code when those services:

  • Represent the standard of care for the overall procedure, or
  • Are necessary to accomplish the comprehensive procedure, or
  • Do not represent a separately identifiable procedure unrelated to the comprehensive procedure.

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16.15 Incorrect Coding

Examples of incorrect coding include:

  • "Unbundling" - Fragmenting one service into components and coding each as if it were a separate service.
  • Billing separate codes for related services when one code includes all related services.
  • Breaking out bilateral procedures when one code is appropriate.
  • Downcoding a service in order to use an additional code when one higher level, more comprehensive code is appropriate.

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16.16 Modifiers

Appropriate modifiers must be billed in order to reflect services provided and for claims to pay appropriately. MCP can request copies of operative reports or office notes to verify services provided. Common modifier issue clarification is below:

  • Modifier 59 - Distinct Procedural Services - must be attached to a component code to indicate that the procedure was distinct or separate from other services performed on the same day and was not part of the comprehensive service. Medical records must reflect appropriate use of the modifier. Modifier 59 cannot be billed with evaluation and management codes (99201-99499) or radiation therapy codes (77261 -77499).
  • Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service - must be attached to a component code to indicate that the procedure was distinct or separate from other services performed on the same day and was not part of the comprehensive service. Medical records must reflect appropriate use of the modifier. Modifier 25 is used with evaluation and management codes and cannot be billed with surgical codes.
  • Modifier 50 - Bilateral Procedure - If no code exists that identifies a bilateral service as bilateral, you may bill the component code with modifier 50. MCP follows the same billing process as CMS and AHCCCS when billing for bilateral procedures. Services should be billed on one line reporting one unit with a 50 modifier.

Please refer to your Current Procedural Terminology (CPT) manual for further detail on all modifier usage.

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16.17 Medical Claims Review

To ensure medical appropriateness and billing accuracy, any inpatient and outpatient outlier claims are sent for Medical Claims Review. An outlier is identified on the claim with a condition code of 61 and is used to identify claims with extraordinary cost per day. For inpatient outlier claims, this includes those that are greater than $60,000 billed if covered costs per day exceed the statewide average cost threshold.

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16.18 Checking Status of Claims

Providers may check the status of a claim by accessing MCP's secure website or by calling the Claims Inquiry Claims Research (CICR) department.

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Online Status through MCP's Secure Website

MCP encourages providers to take advantage of using online status, as it is quick, convenient and can be used to determine status for multiple claims. To register, go to http://www.MercyCarePlan.com and select "Login" at the top of the page or contact your Provider Relations representative to establish a Login. More information is available in this Provider Manual under section 4.35 MercyOneSource.

Calling the Claims Inquiry Department

The Claims Inquiry department is also available to:

  • Answer questions about claims.
  • Assist in resolving problems or issues with a claim.
  • Provide an explanation of the claim adjudication process.
  • Help track the disposition of a particular claim.
  • Correct errors in claims processing:
    • Excludes corrections to prior authorization numbers (providers must call the Prior Authorization department directly).
    • Excludes rebilling a claim (the entire claim must be resubmitted with corrections, see section 16.20 Claim Resubmission or Reconsideration.

Please be prepared to give the service representative the following information:

  • Provider name and AHCCCS provider number with applicable suffix if appropriate.
  • Member name and AHCCCS member identification number.
  • Date of service.
  • Claim number from the remittance advice on which you have received payment or denial of the claim.

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16.19 Payment of Claims

MCP processes and records payment of claims through a Remittance Advice. Providers may choose to receive checks through the mail or electronically. MCP encourages providers to take advantage of receiving Electronic Remittance Advices (ERA), as you will receive much sooner than receiving through the mail, enabling you to post payments sooner. Please contact your Provider Relations representative for further information on how to receive ERA. Remittance Advice samples are available under Mercy Care Plan/Provider Tools/Forms. Links to those remits are available under the section 16.25 Provider Remittance Advice in this Provider Manual.

Through Electronic Funds Transfer (EFT), providers have the ability to direct funds to a designated bank account. MCP encourages you to take advantage of EFT. Since EFT allows funds to be deposited directly into your bank account, you will receive payment much sooner than waiting for the mailed check. You may enroll in EFT by submitting a Mercy Care Plan EFT Enrollment Form, found under the Mercy Care Plan/Provider Tools/Forms section. Submit this form along with a voided check to process the request. Please allow at least 30 days for EFT implementation. Your Provider Relations representative will assist you with this.

Additional information can be attained by accessing the Mercy Care Plan/Provider Tools/Provider Notification titled Electronic Submission of Claims/Electronic Fund Transfer/ Electronic Remittance Advice.

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16.20 Claim Resubmission or Reconsideration

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 Mercy Care Plan/Provider Tools/Forms section.
  • An updated copy of the claim. All lines must be rebilled or a copy of the original claim (reprint or copy is acceptable).
  • 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 16.12b Claim Address Table.

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.

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INSTRUCTION FOR SPECIFIC CLAIMS TYPES

16.21 MCP General Claims Payment Information

MCP claims are always paid in accordance with the terms outlined in the PHPÕs contract. Prior authorized services from Non PHPs will be paid in accordance with AHCCCS processing rules.

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16.22 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 Mercy Care Plan/Provider Tools/Provider Notifications for additional information.

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16.23 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.

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16.24 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 Services and Appropriate Billing Codes under the Mercy Care Plan/Provider Tools/Provider Notifications for additional billing information.
  • Family Planning services may be billed with other services on the same claim. When billed on the same claim though, a provider will receive two remits, one for family planning services and one for non-family planning services, as these services are paid out of separate funds.
  • Family Planning claims may be submitted electronically.

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

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16.25 Complete Obstetrical Care Package

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

Services Included in the Package
  • Initial and subsequent prenatal visits, including early, periodic, screening, diagnosis and treatment services (EPSDT - see below) for patients less than 21 years of age
  • Treatment of pregnancy related conditions, including hypertension and gestational diabetes
  • Treatment of urinary tract infections and pelvic infections
  • Routine labs and blood draws
  • In-hospital management of threatened premature labor
  • In-hospital management of hyperemesis gravidarum
  • External cephalic version performed in hospital
  • Induction of labor by prostaglandins and/or oxytocin and/or combined
  • Amnioinfusion
  • Trial of vaginal birth after a cesarean (VBAC)
  • Delivery by any method, including cesarean section
  • Episiotomy and repair, including 4th degree lacerations
  • All routine post partum care, including follow-up visit
  • Any management that would ordinarily be considered part of OB care.

Services will not be separately reimbursed if billed separately.

If a provider does not complete all the services in the Global Obstetrical Care Package, this may result in a lesser payment or potential recoupment of payments made.

Services Not Included in the Package
  • Amniocentesis
  • Obstetrical Ultrasonography
  • Non-stress and contraction stress tests
  • Coloscopy and/or biopsy for accepted indication
  • Return to operating or delivery room for postpartum hemorrhage/curettage
  • Non-obstetrical related medical care
  • Cerclage.

Separate reimbursement will be provided, if medically necessary.

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16.26 Trimester of Entry into Prenatal Care

Claims for obstetrical services are submitted on CMS 1500 Form. Health providers must bill Evaluation and Management codes with the date span, and zero charges on one line and the total OB service charges on another. The health professional must indicate the date of the first prenatal visit as well as identify the total number of prenatal visits provided.

While the goals of early entry into prenatal care and regular care during pregnancy have not changed, HEDIS guidelines will be followed to determine trimester of entry into prenatal care. Entry into prenatal care and the number of prenatal visits are measured and monitored by MCP and AHCCCS as part of the Quality Management Program.

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16.27 Provider Remittance Advice

MCP generates checks weekly. Claims processed during a payment cycle will appear on a remittance advice ("remit") as paid, denied or reversed. Adjustments to incorrectly paid claims may reduce the check amount or cause a check not to be issued. Please review each remit carefully and compare to prior remits to ensure proper tracking and posting of adjustments. We recommend that you keep all remittance advices and use the information to post payments and reversals and make corrections for any claims requiring resubmission. Call your Provider Relations representative if you are interested in receiving electronic remittance advices. Additional information can be attained by accessing the Mercy Care Long Term Care/Provider Tools/Provider Notifications titled Electronic Submission of Claims/Electronic Fund Transfer/Electronic Remittance Advice.

The Provider Remittance Advice (remit) is the notification to the provider of the claims processed during the payment cycle. A separate remit is provided for each line of business in which the provider participates.

Information provided on the remit includes:

  • The Summary Box found at the top right of the first page of the remit summarizes the amounts processed for this payment cycle.
  • The Remit Date represents the end of the payment cycle.
  • The Beginning Balance represents any funds still owed to MCP for previous overpayments not yet recouped or funds advanced.
  • The Processed Amount is the total of the amount processed for each claim represented on the remit.
  • The Discount Penalty is the amount deducted from, or added to, the processed amount due to late or early payment depending on the terms of the provider contract.
  • The Net Amount is the sum of the Processed Amount and the Discount/Penalty.
  • The Refund Amount represents funds that the provider has returned to MCP due to overpayment. These are listed to identify claims that have been reversed. The reversed amounts are included in the Processed Amount above. Claims that have refunds applied are noted with a Claim Status of REVERSED in the claim detail header with a non-zero Refund Amount listed.
  • The Amount Paid is the total of the Net Amount, plus the Refund Amount, minus the Amount Recouped.
  • The Ending Balance represents any funds still owed to MCP after this payment cycle. This will result in a negative Amount Paid.
  • The Check # and Check Amount are listed if there is a check associated with the remit. If payment is made electronically then the EFT Reference # and EFT Amount are listed along with the last four digits of the bank account the funds were transferred. There are separate checks and remits for each line of business in which the provider participates.
  • The Benefit Plan refers to the line of business applicable for this remit. TIN refers to the tax identification number.
  • The Claim Header area of the remit lists information pertinent to the entire claim. This includes:
    • Member/Patient Name
    • ID
    • Birth Date
    • Account Number,
    • Authorization ID, if Obtained
    • Provider Name,
    • Claim Status,
    • Claim Number
    • Refund Amount, if Applicable
  • The Claim Totals are totals of the amounts listed for each line item of that claim.
  • The Code/Description area lists the processing messages for the claim.
  • The Remit Totals are the total amounts of all claims processed during this payment cycle.
  • The Message at the end of the remit contains claims inquiry and resubmission information as well as grievance rights information.

The following Remittance Advice samples are available under Provider Tools or by clicking on the form listed below:

  • Mercy Care HCG Remit Format for Check
  • Mercy Care HCG Remit Format for EFT
  • Mercy Care Plan Remit Format for Check
  • Mercy Care Plan Remit Format for EFT
  • SA FPS Remit Format for Check
  • SA FPS Remit Format for EFT

More information is available in this Provider Manual under section 4.35 MercyOneSource regarding Remittance Advice Search.

An electronic version of the Remittance Advice can be attained. In order to qualify for an Electronic Remittance Advice (ERA), you must currently submit claims through EDI and receive payment for claim by EFT. You must also have the ability to receive ERA through an 835 file. We encourage our providers to take advantage of EDI, EFT, and ERA, as it shortens the turnaround time for you to receive payment and reconcile your outstanding accounts. Please contact your Provider Relations Representative to assist you with this process.

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CHAPTER 17 - GRIEVANCES, APPEALS AND CLAIM DISPUTES

17.0 Grievances

A grievance is an expression of dissatisfaction about any matter other than an action. A grievance is not related to a denial of claims payment or claims reimbursement. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the member's rights.

A provider is permitted to file a grievance with a contractor at the contractor's discretion. A provider may file a grievance in writing to:

Mercy Care Plan
Member Services Department
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040

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17.1 Provider Claim Disputes

A claim dispute is a dispute involving the payment of a claim, denial of a claim, imposition of a sanction or reinsurance. A provider may file a claim dispute based on:

  • Claim Denial
  • Recoupment
  • Dissatisfaction with Claims Payment

Before a provider initiates a claims dispute, the following needs to occur:

  • The claim dispute process should only be used after other attempts to resolve the matter have failed.
  • The provider should contact MCP Claims and/or Provider Relations to seek additional information prior to initiating a claim dispute.
  • The provider must follow all applicable laws, policies and contractual requirements when filing.
  • According to the Arizona Revised Statute, Arizona Administrative Code and AHCCCS guidelines, all claim disputes related to a claim for system covered services must be filed in writing and received by the administration or the prepaid capitated provider or program contractor:
  • Within 12 months after the date of service.
  • Within 12 months after the date that eligibility is posted.
  • Or within 60 days after the date of the denial of a timely claim submission, whichever is later.

Submit a written claim dispute to the MCP Appeals Department. Include all supporting documentation with the initial claim dispute submission. The claim dispute must specifically state the factual and legal basis for the relief requested, along with providing copies of any supporting documentation, such as remittance advice(s), medical records or claims. Failure to specifically state the factual and legal basis may result in denial of the claim dispute.

MCP will acknowledge a claim dispute request within five (5) business days after receipt. If a provider does not receive an acknowledgement letter within five (5) business days, the provider must contact the Appeals Department. Once received, the claim dispute will be reviewed, and a decision will be rendered within 30 days after receipt. MCP may request an extension of up to 45 days, if necessary. The claim dispute, including all supporting documentation, should be sent to:

Mercy Care Plan
Appeals Department
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
602-351-2300 (FAX)

If a provider disagrees with the MCP Notice of Decision, the provider may request a State Fair Hearing. The request for State Fair Hearing must be filed in writing no later than 30 days after receipt of the Notice of Decision. Please clearly state "State Fair Hearing Request" on your correspondence. All State Fair Hearing Requests must be sent in writing to the follow address:

Mercy Care Plan
Appeals Department
Attention: Hearing Coordinator
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
602-351-2300 (fax)

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17.2 Appeals

An appeal is a request for review of an action by an enrollee (member) or their authorized representative, such as a provider. An appeal can be filed for various reasons including the denial or limited authorization of a requested service, the type or level of service, or for the reduction, suspension or termination of a previously authorized service. An authorized representative acting on behalf of the member, with the member's written consent, may file an appeal or request a State Fair Hearing on behalf of a member.

  • Standard Appeals - An appeal must be filed either orally or in writing with MCP within 60 days after the date of the Notice of Action. A provider may assist a member in filing an appeal. MCP does not restrict or prohibit a provider from advocating on behalf of a member.
  • Standard Appeal Resolution - MCP will resolve the appeal and mail the written Notice of Appeal Resolution to the member within 30 days after the day MCP receives the appeal.
  • Expedited Appeals - If a provider believes that the time for a standard resolution appeal could seriously jeopardize the member's life, health, or ability to attain, maintain, or regain maximum function, the provider can submit a request for an Expedited Appeal, with the member's written consent, along with supporting documentation to MCP. MCP will acknowledge an expedited appeal within one working day of receipt.
  • Expedited Appeal Resolution

    MCP will resolve the appeal and mail a written Notice of Appeal Resolution to the member within 3 working days after MCP receives the Expedited Appeal. MCP will also make reasonable efforts to provide prompt oral notification to the member. This timeframe may be extended if MCP needs additional information and the extension is in the best interest of the member. If the request for an Expedited Appeal is denied, MCP will decide the appeal within the standard timeframe (30 days from the day MCP receives the Expedited Appeal).

In order to file an appeal, please submit in writing, along with all substantiating documentation to:

Mercy Care Plan
Appeals Department
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
602-351-2300 (FAX)

A member may also file an Appeal orally by contacting:

Mercy Care Plan
Appeals Department
Phone: (602) 453-6098
Toll Free: (800) 624-3879

An authorized representative, including a provider, acting on behalf of the member, with the member's written consent, may request a State Fair Hearing on behalf of the member. The request for State Fair Hearing must be in writing, submitted to and received by MCP, no later than 30 days after the date the member receives the Notice of Appeal Resolution.

All State Fair Hearing Requests must be sent in writing to the follow address:

Mercy Care Plan
Appeals Department
Attention: Hearing Coordinator
4350 E. Cotton Center Boulevard, Building D
Phoenix, AZ 85040
602-351-2300 (fax)

CHAPTER 18 - FRAUD AND ABUSE

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18.0 Fraud and Abuse Overview

MCP supports efforts to detect, prevent and report fraud and abuse within the Medicaid system. These efforts are consistent with our mission to provide care to the poor and those with special needs while exercising sound fiscal responsibility. Management of limited resources is a key part of this responsibility.

Fraudulent activity hurts everyone. We hope you will join us in our efforts to ensure that tax dollars spent for health care are spent responsibly and used to provide necessary care for as many members as possible.

Examples of actions that are reportable to the state's investigative agencies include:

  • Physical or sexual abuse of members.
  • Improper billing and coding of claims.
  • Pass through billing.
  • Billing for services not rendered.
  • Raising fees for Medicaid patients to allowable amounts if these fees are not billed to other patients.
  • Unbundling and upcoding may be construed as fraud if a pattern is found to exist.

In addition, member fraud is also reportable and examples include:

  • Use of another member's identification to obtain services.
  • Fraudulent application for eligibility.
  • Sale of durable medical equipment while on loan to members.
  • Prescription fraud.

MCP is required to report cases of suspected fraud or abuse to the AHCCCS Office of Program Integrity. Other agencies may have involvement in cases of criminal activity or abuse. The Office of Program Integrity is responsible for determining if suspected fraud or abuse cases warrant referral to the State Attorney General's office.

Anyone who suspects member or provider fraud or abuse may report it either to the MCP hotline number at (800) 810-6544 or directly to the State hotline at:

  • In Maricopa County: (602) 417-4045
  • Outside of Maricopa County: (888) ITS-NOT-OK or (888) 487-6686.

AHCCCS has recently published to its website an e-learning seminar entitled "Fraud Awareness for Providers" that discusses provider and member fraud. This seminar is available at the following website:

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www.azahcccs.gov/commercial

MCP would like to inform you of this valuable seminar's availability and would like to encourage our providers and their office staff to review/listen to this short seminar for additional information regarding fraud awareness.

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18.1 Deficit Reduction Act and False Claims Act Compliance Requirements

Each Provider Agreement requires all providers to adhere to Deficit Reduction Act (DRA) requirements. The DRA requires that any entity (which receives or makes payments, under a state plan approved under Title XIX or under any waiver of such plan, totaling at least $5 million annually) must establish written policies for its employees, management, contractors and agents regarding the False Claims Act (FCA). The FCA applies to claims presented for payment by federal health care programs. The FCA allows private persons to bring a civil action against those who knowingly submit false claims upon the government.

Activities for which one may be liable under the FCA:

  • Knowingly presenting to an officer or employee of the United States government a false or fraudulent claim for payment or approval.
  • Knowingly making, using, or causing a false record or statement to get a false or fraudulent claim paid or approved by the government.
  • Conspiring to defraud the government by getting false or fraudulent claims allowed or paid.
  • Having possession, custody, or control of property or money used, or to be used by the government and, intending to defraud the government by willfully concealing property, delivering, or causing to be delivered less property than the amount for which the person receives.
  • Authorizing to make or deliver a document, certifying receipt of property used by the government and intending to defraud the government and making or delivering a receipt without completely knowing that the information on the receipt is true;
  • Knowingly buying, or receiving as a pledge of an obligation or debt, public property from an officer or employee of the government, or a member of the Armed Forces, who lawfully may not sell or pledge the property; or
    • Knowingly making, using or causing to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government.
    • The definition of "knowing" and "knowingly" as it relates to the FCA includes actual knowledge of the information, acting in deliberate ignorance of the truth or falsity of the information, and/or acting in reckless disregard of the truth or falsity of the information. Proof of specific intent to "defraud" is not required for reporting potential violations of the law.

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18.2 False Claims Training Requirements

As required by MCP's contract with AHCCCS Administration, providers must train their staff on the following:

  • The administrative remedies for false claims and statements.
  • Any state laws relating to civil or criminal penalties for false claims and statements.
  • The whistleblower (or relater) protections under such laws.

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18.3 Administrative Remedies for False Claims and Statements

The United States Government (Government) has administrative remedies available to it in cases that have resulted in FCA violations. The administrative remedy for violating the FCA is three times the dollar amount that the government is defrauded and civil penalties of $5,500 to $11,000 for each false claim by the party responsible for the claim. If there is a recovery in the case brought under the FCA, the person bringing suit (relater) may receive a percentage of the recovery against the party that had responsibility for the false claim. For the party that had responsibility for the false claim, the government may seek to exclude it from future participation in federally funded health care programs or impose integrity obligations against it.

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18.4 State Laws Relating To Civil or Criminal Penalties or False Claims and Statements

To prevent and detect fraud, waste, and abuse, many states have enacted laws similar to the FCA but with state-specific requirements, including administrative remedies and relater rights. Those laws generally prohibit the same types of false or fraudulent claims for payments for health care related goods or services as are addressed by the federal FCA. For further information on specific state law requirements, contact MCP's Compliance Office.

Additional information on the Deficit Reduction Act and False Claims Act is available on the following websites:

  • Deficit Reduction Act - Public Law 109-171: Link
  • Arizona Revised Statutes (ARS): Link
  • ARS 13-1802: Theft
  • ARS 13-2002: Forgery
  • ARS 13-2310: Fraudulent schemes and artifices
  • ARS 13-2311: Fraudulent schemes and practices; willful concealment
  • ARS 36-2918: Duty to report fraud

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4350 E. Cotton Center Blvd.,
Bldg D, Phoenix,
Arizona 85040
Member Services
7 a.m. to 6 p.m. Monday-Friday
602-263-3000,
Toll-free 1-800-624-3879
(TTY/TDD)
Toll-free: 1-866-602-1982

If you or a family member has a medical emergency, dial 911.