Member Information

Your needs are our top priority

Keeping you healthy is important to us. In this section you will find additional information to help you understand your plan. 

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 the provider's responsibility to treat a member based on their needs.
  • Substitute as orders for treatment of a member.
  • Guarantee coverage or payment for the type or level of care proposed by a provider.

We have adopted these guidelines for:

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:

Health maintenance
exam by age

  • 18-25
  • 26-39
  • 40-49
  • 50-65
  • 65 and older
  • Every 5 years
  • Every 5 years
  • Every 3 years
  • Every 1-2 years
  • Every 1-2 years

Cervical cancer screening 

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.

Diabetes screening

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.



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)

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.


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.


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 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.

In May 2016, the Centers for Medicare & Medicaid Services (CMS) approved Mercy Care Advantage to process Seamless Conversion Enrollments.  Seamless Conversion Enrollment is an enrollment method that allows Mercy Care Advantage to automatically enroll Mercy Care Plan members who are becoming Medicare eligible due to turning 65 or reaching the end of their 24‐month Medicare disability-waiting period.  In October 2016, we began notifying eligible Mercy Care Plan members in writing to explain they will be automatically enrolled in Mercy Care Advantage as of their Medicare entitlement effective date.  The notice explains the benefits of being a Mercy Care Advantage member and how this plan will help coordinate with their Mercy Care Plan coverage.  Members do have the option to “Opt-Out” of the Mercy Care Advantage plan prior to their enrollment effective date.  

Mercy Care Advantage is making outreach calls to eligible members to explain the plan benefits and assist with questions. If you have questions about the Mercy Care Advantage Seamless Enrollment process, please call our Seamless Enrollment team at 1-866-277-1025, (TTY 711), Monday through Friday from 8:00 a.m. – 5:00 p.m.

View an example of the Seamless Enrollment Initial Notice letter