Member Information

Your needs are our top priority

Keeping you healthy is important to us. In these pages you will find information to help you understand your plan. We want to help you manage your health and improve your care. We are here to help. If you are a plan member, please contact us  to let us know if you need help with:

  • Understanding your health plan and covered benefits
  • Finding a doctor or hospital in our network or to request a provider directory (You can also find a provider online)
  • Finding an interpreter
  • Getting information about behavioral health services
  • Scheduling a ride to or from a health care appointment

Mercy Care Member Services 7 a.m.-6 p.m., Monday-Friday 602-263-3000 or 1-800-624-3879 (TTY/TDD 711)

 

Your Office of Individual and Family Affairs

Mercy Care’s OIFA team believes that recovery is possible for everyone. We help by providing support to members and their families of choice. If you need help or have concerns about your care, you can reach out to us at OIFATeam@MercyCareAZ.org.

You can also call our ombudsman. An ombudsman is someone who is an advocate for members and their family members and helps them navigate the system. Note: The ombudsman will return your call or email within 48 hours.

Vera Kramarchuk, ombudsman
KramarchukV@MercyCareAZ.org
Office: 602-414-7626
Cell: 480-404-3417

Do you need help managing your health?
Sometimes you need some extra help to cope with a health issue. That’s why we offer Care Management.

Not everyone needs a care manager, but those who do, mostly need one for a short time. A care manager can show you how to get services to improve your health. Our goal is to help you learn how to take care of yourself.

If you answer yes to any of these questions, you may want to ask about getting Care Management services.

  • Do you go to the ER a lot?
  • Are you having a hard time getting your medication or supplies that your doctor ordered?
  • Do you need help getting on the Arizona Long Term Care System?
  • Do you have HIV?
  • Do you have medical conditions, such as high blood pressure, diabetes, asthma and congestive heart disease, that don’t get better with medication?
  • Do you not know why your primary care doctor is sending you to a specialist provider?
  • Are you pregnant and having problems?
  • Are you a pregnant teenager?
  • Are you pregnant and over 35 years old?
  • Did you have a baby born too early?

If you answered yes, you can ask your doctor to refer you for Care Management services. You can also call Mercy Care Plan directly. A nurse will look at your request and decide if you need to meet with a care manager.

If you have one of the following medical conditions:  depression, high blood pressure, diabetes, asthma or congestive heart disease, please contact us so we can help you take care of your disease.

To request a medical care manager, please call: 602-453-8391

To request a care manager during your pregnancy, please call: 602-798-2703

 

When to Use the Emergency Room

New co-pay requirement for non-emergent use of the Emergency Room. Mercy Care adult members will soon be required by the Arizona Cost Containment System (AHCCCS) to pay an $8.00 co-pay when using the emergency room for a non-emergency.

How to tell if it's an emergency Emergencies are life-threatening. Here are examples of things that are NOT emergencies and some that are. If you are not sure, call your doctor. You call also call the Nurse Line at 602-263-3000 or 1-800-624-3879 and select the "speak to a nurse" option. The nurse line is available 24 hours a day/7 days per week, and is available to answer general medical questions.

Non-Emergencies:

  • Flu
  • Cold
  • Sore throat
  • Earache
  • Headache
  • Prescription refill or request
  • Back strain

Emergencies:

  • Poisoning/overdose
  • Severe chest pain
  • You cannot move your arms or legs
  • Bleeding that you cannot stop
  • Loss of consciousness
  • Deep cuts or serious burns
  • Pregnant with severe bleeding and/or pain 

 

Is it really an emergency? The emergency room (ER) is for serious problems like heart attacks, broken bones, bad burns and car accidents. If your life or your child's life is in danger or you have a real emergency, call 9-1-1 right away or go to the closest ER. But, if you go to the ER because you think you will be seen more quickly, you will most likely have to wait. In the ER, anything except a real emergency has to wait, even if you were there first. You may also have to pay a co-payment. This is because you went to the ER but did not have an emergency.

When to use Urgent Care

Do you need urgent medical care? Can't get an appointment with your doctor?

Mercy Care members may go to contracted urgent care centers for urgent medical problems. Urgent care doctors treat both children and adults. If you get sick or have an accident, call your doctor first If you can't get a same day appointment you can still get medical care right away. Go to an urgent care center for things like:

  • Flu, bad sore throats, earaches
  • Back pain
  • Migraine headaches
  • Sprains

 

For a complete listing of Mercy Care urgent care centers go to Find a provider at the top of the page.

 

DispatchHealth

Mercy Care members can now get care in the comfort of your home. We’ve partnered with DispatchHealth, a company that delivers urgent care to you. Instead of going to the ER or to urgent care, an ER-trained medical team can come to your home in a few hours. You can stay home and focus on feeling better. Just call 480-493-3444, 7 days a week, 8 a.m. to 8 p.m. or visit dispatchhealth.com. DispatchHealth treats everything an urgent care can, plus more. Including common conditions like:

  • Fever / flu
  • Headaches / migraines
  • Urinary tract infection
  • Asthma
  • Seasonal allergies
  • Upper respiratory tract infection
  • Eye infection or irritation
  • Pink eye
  • Skin infection / rash
  • Nausea / vomiting
  • Diarrhea
  • Constipation

 

 

To help provide our members with consistent, high-quality care that utilizes services and resources effectively, we have chosen certain clinical guidelines to help our providers. These are treatment protocols for specific conditions as well as preventive health guidelines.

These guidelines are intended to clarify standards and expectations. They should not:

  • Come before your responsibility to provide treatment based on the member’s individual needs.
  • Substitute as orders for treatment of a member.
  • Guarantee coverage or payment for the type or level of care proposed or provided.

We have adopted the these evidence-based guidelines.

To learn more about the guidelines and to access helpful tool kits on treating various behavioral disorders, follow the links below:

Arizona Opioid Prescribing Guidelines

Clinical guidelines for the treatment of children

If you are a pediatrician or family medicine practitioner working with children, make sure you fully understand the Early Periodic Screening, Diagnosis and Treatment (EPSDT) Program and are familiar with the Childhood Immunization Schedule.

  • EPSDT Program: To help ensure children under age 18 get the screenings and preventive care they need, please refer to the EPSDT Periodicity Schedule.

Childhood Immunization Schedule

Clinical guidelines for the treatment of adults

As patients age, it remains important that we catch diseases as early as possible to be able to provide the best care that can lead to the best possible outcomes. Learn more about preventive and treatment guidelines for specific conditions in adults.

  • Adult immunization schedule: Don’t forget – kids aren’t the only ones who need immunizations. Make sure adult members are up-to-date on their influenza, Hepatitis A and B, MMR and other vaccines.
  • Community-Acquired Pneumonia (CAP) Clinical: The CAP Clinical Guidelines is to develop an integrated approach to the outpatient management of CAP with an emphasis on prevention, early detection and patient education. View  guidelines from the Infectious Diseases Society of America website and American Thoracic Society Consensus.
  • HIV guidelines: Mercy Care advises providers to refer to the guidelines and resources provided by the National Institutes of Health on its website.
  • Preventive health care guidelines for adults:

Test

  • 18-25
  • 26-39
  • 40-49
  • 50-65
  • 65 and older

(health maintenance exam by age)

 

Pap tests (cervical cancer screening)

Diabetes screening

Frequency

  • Every 5 years
  • Every 5 years
  • Every 3 years
  • Every 1-2 years
  • Every 1-2 years

Every one to three (1-3) years starting at age 18 or when sexually active. Frequency may decrease when there is no history of abnormal Pap tests and three or more tests are normal.

Test at age 45 for adults with no symptoms and then every three (3) years.

Treating behavioral health disorders in children

If you are treating children with behavioral health disorders, Mercy Care offers a variety of resources related to anxiety, depression and ADHD. Click on the links below to download PDFs of these resources and tools.

Anxiety

Depression

Attention Deficit/Hyperactivity Disorder (ADHD)

Treating behavioral health disorders in adults

The follow resources are intended to help behavioral health providers diagnose and treat behavior health disorders in adults. Click on the links below to download PDFs of the tool kits.

 

Mercy Care uses nationally recognized and/or community-developed, evidence-based criteria to make decisions about medical necessity.

The criteria is applied based on the needs of our members and characteristics of the local delivery system. The staff that make medical necessity determinations are trained on the criteria. And, the criteria they use is accepted and reviewed based on Mercy Care’s policies and procedures.

The criteria is reviewed annually by the proper practitioners. They help in developing, adopting, or reviewing criteria. They also make sure it’s r for our member’s needs. The criteria is also updated when national or community-based clinical practice guidelines are updated. 

We apply the criteria consistently, considering the needs of members. We consult with requesting practitioners/providers when it’s appropriate.

For inpatient medical care reviews, Mercy Care uses the following criteria:

  • Criteria required by applicable state or federal regulatory agency
  • Applicable Milliman Care Guidelines (MCG) as the primary decision support for most clinical diagnoses and conditions
  • Aetna Clinical Policy Bulletins (CPB’s) 
  • Aetna Clinical Policy Council Review (ad hoc)

For inpatient behavioral health care reviews, Mercy Care uses the following criteria:

  • Criteria required by applicable federal and state regulatory agencies
  • Milliman Care Guidelines (MCG). These are care management guidelines based on the latest research and scholarly articles and data analysis.
  • American Society of Addiction Medicine (ASAM) PPC-2R. This is a guide that provides guidelines about the proper type of care and the level of intensity of care for people with addictive diseases.
  • The Child and Adolescent Service Intensity Instrument (CASII). This is a standardized assessment tool that provides a determination of the appropriate level of service intensity needed by a child or youth and his or her family.
  • The Level of Care Utilization System (LOCUS). This is tool designed by the American Association of Community Psychiatrists. It allows staff who work on inpatient hospital environments with patients with psychiatric problems (such as emergency departments, psychiatric sections of general hospitals or in psychiatric hospitals) to determine the level of care that an individual should receive.
  • Aetna Clinical Policy Bulletins (CPBs)
  • Aetna Clinical Policy Council Review (ad hoc)

You can view or download the results of the Mercy Care member and provider surveys:

Member - Learn about how Mercy Care members rate their experiences and satisfaction.

Provider - Learn about how Mercy Care providers rate their experiences and satisfaction.

You can also view the following AHCCCS Member Satisfaction Surveys on the AHCCCS website: Member Survey Results, Provider Survey Results, Performance Measure Results and AHCCCS Performance Measures.

Getting specialty services

There are times when a health problem can’t be treated by your doctor alone and specialty care may be needed. If you need care from a specialty provider, your PCP will need to request a referral or prior authorization for you. Some covered medical services will need prior authorization before you can receive the service.

Referrals

A referral is when your primary care provider (PCP) sends you to a specialist provider for a specific problem. This might include heart problems, skin disorders or serious allergies. A referral can also be to a lab or hospital, etc. You may also request a second opinion from another Mercy Care doctor.

Self-referral

You don't need a referral from your provider for these services:

  • Dental services
  • OB/GYN covered services
  • Behavioral health and substance use services 
  • Family planning services

Prior authorizations

A prior authorization is an approval from Mercy Care for you to get the special services your PCP or specialist provider wants you to receive. We may take up to 14 days to approve a routine authorization request and three (3) business days to approve an urgent request.

If we need additional information to authorize the request, a 14-day extension may be requested. If we do not receive the information requested from your doctor, we may deny the request. You will receive a notice of action letter that explains your rights. 

If your doctor sends in an urgent authorization request and it does not meet the criteria for an urgent request, we will send you a letter and let you know that it will be processed as a regular request. You can file a grievance if you disagree. Please go to Grievances for more information.

Click on the link below to see if a service requires pre-approval. You do not need approval from Mercy Care to get emergency services.

Mercy Care providers are expected to follow certain guidelines when giving our members care. If you need help understanding any of these guidelines, please call Member Services and ask to speak to a nurse who can help you.

Certain acute outpatient services and planned hospital admissions require prior authorization before the service can be covered. Please refer to the Evidence of Coverage for more explanation about which services and circumstances require prior authorization.