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 Opens In New Window 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)

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

Not everyone needs a case manager, but those who do, mostly need one for a short time. A case 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 Case 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 Case 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 case 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 case manager, please call: 602-453-8391

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

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 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)

The more you know, the better equipped you’ll be to make the best decisions for your health. From general health tips to ideas for managing your care, information is power. Each issue of our newsletter is filled with health tips and information that’s important to you. To request a newsletter be mailed to you, please contact us. 

Health Matters

Long Term Care Connection

Pregnancy Connection

Disease Management Newsletters

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 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.

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 links 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.