Member Information

Your Member Services

Your Office of Individual and Family Affairs

Care (Disease) Management

The Mercy Care ACC-RBHA Care Management program is designed to improve your health outcomes. We make sure those who need extra support get the right care, in the right setting and in a way that is respectful of beliefs and traditions.

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 improve your health and wellness so you don't have to make frequent visits to the emergency room. We want to make sure you have the tools you need to manage your care.

Members that may benefit from this intensive care management include those who:

• Require Special Assistance 
• Struggle to managed chronic conditions (For example, diabetes, high blood pressure, COPD, congestive heart disease)
• Frequently use the ER for ongoing issues
• Have recent multiple hospitalizations
• Are diagnosed with HIV
• Are pregnant
• Have multiple transitions of care

A care manager can help.
If you qualify for care management, a care manager will develop a plan of care that is specially designed for you. It will support the your physical and behavioral health, social and community service needs, preferences, placement goals and figure out ways to overcome barriers you might be facing. And, that plan will change as the your needs change.

Want to learn more?
Call Member Services at 602-586-1841 or 1-800-564-5465; (TTY/TDD) 711. Representatives are available 24 hours a day, 7 days a week.

Clinical Practice Guidelines

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:

• Mercy Care children
• Mercy Care adult and children

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

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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

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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	Frequency
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.

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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

• Tool Kit for Childhood & Adolescent Anxiety

Depression

• Tool Kit for Childhood & Adolescent Depression Management

Attention Deficit/Hyperactivity Disorder (ADHD)

• Tool Kit for Childhood & Adolescent ADHD Management

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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.

• Tool Kit for Management of Adult ADHD
• Tool Kit for the Management of Adult Anxiety
• Tool Kit for the Management of Adult Depression
• Tool Kit for Postpartum Depression Management

Medical Determination Criteria

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)

Emergency and Urgent care

How to tell if it's an emergency

Emergencies are life-threatening. Here are some examples of 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 

Here are examples of things that are NOT emergencies:

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

Non-emergency services
There are many places where you can find care at all times of the day or night, and avoid waiting in a hospital emergency room. That includes health care clinics, community health centers and urgent care facilities. You can find these providers on the Find a provider link at the top of the page.

You can also contact Mercy Care RBHA Member Services at 602-586-1841 or 1-800-564-5465; (TTY/TDD 711). Representatives are available 24 hours a day, 7 days a week.

If you become sick or hurt, call your doctor first
Except in a real emergency, if you or someone you care about gets sick after the doctor’s office is closed or on a weekend, call the office anyway. Primary Care Physicians (PCPs) have answering services that will make sure your doctor gets your message. Your PCP will call you back to tell you what to do. Make sure your phone is "unblocked" or the doctor may not be able to reach you.

Remember, if someone’s life is in danger, call 911 or go to the closest emergency room (ER). You don't need approval from Mercy Care to go to the ER or to urgent care services.

Behavioral health crisis 
If you are experiencing a behavioral health crisis, you can call one of the crisis lines in Arizona. Someone is available 24 hours day, 7 days a week to provide crisis intervention, support and referrals.

Central Arizona Crisis Line:
602-222-9444 or 800-631-1314 (toll-free)
TTY: 602-274-3360 or 800-327-9254

Northern Arizona Crisis Line:
877-756-4090

Southern Arizona Crisis Line:
866-495-6735

Member and Provider Survey Results

Arizona Health Care Cost Containment System (AHCCCS) member surveys - AHCCCS conducts Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys on a regular basis to better understand member satisfaction with the contracted Managed Care Organizations (MCOs) and/or member satisfaction with the overall AHCCCS healthcare delivery system.

AHCCCS Provider Survey Results - Learn about AHCCCS provider surveys.

AHCCCS Health Plan Report Card - Learn about how members compare contracted health plans by line of business.

AHCCCS Performance Measure Results - Learn about AHCCCS Performance Measures.

Mercy Care Member Survey Results - Learn about how Mercy Care RBHA behavioral healthcare members rate their experiences and satisfaction.

• 2021 Mercy Care Behavioral Health Member Survey
• 2020 Mercy Care Behavioral Health Member Survey
• 2017 Behavioral Health Member Survey
• 2016 Mercy Care Behavioral Health Member Survey

 

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

• 2016 Mercy Care Plan Provider Survey Results
• 2013 Provider Survey Results

Prior Authorization and Referrals

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 clinical team or provider 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. 

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 Prior Authorization List

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.

Your rights

All members get a notice of adverse benefit determination letter that explains their rights. If your provider sends an urgent authorization request, and it does not meet the criteria for an urgent request, Mercy Care ACC-RBHA sends you a letter to let you know it will be processed as a regular request.

You can file a grievance if you disagree with an extension of time. Please go to Grievances for more information. If you have questions about whether your service has been authorized, call your provider or clinical team.

You do not need approval from Mercy Care to get emergency services.