Claims information

Mercy Care Advantage provides detailed claims processing information for you though our most recently updated Claims Processing Manual - August 2017 (PDF). Please click on the link to access this valuable information. 

It is important to note that balance billing members is prohibited under all Mercy Care health plans.

Under Mercy Care Advantage (MCA)

Mercy Care Advantage (HMO SNP) is a Medicare Advantage Dual Eligible Special Needs Plan, contracted with the Centers for Medicare and Medicaid Services (CMS) to provide services to individuals eligible for Medicare and Medicaid (AHCCCS) coverage. Federal law prohibits balance billing of dually eligible individuals enrolled in the Qualified Medicare Beneficiary (QMB) Program. QMB is a Medicare Savings Program that exempts Medicare beneficiaries from Medicare cost-sharing liability.  Medicare participating providers may not balance bill QMB individuals for Medicare cost-sharing, regardless of whether the State reimburses providers for the full Medicare cost-sharing amounts. Medicare participating providers --not only those that accept Medicaid--must refrain from charging QMB individuals for Medicare cost-sharing. MCA contracted providers must accept the MCA Medicare payment and the Medicaid plan payment (if any) as payment in full for Medicare covered services and benefits.

Refer to our Provider Manuals for more detailed information. Click here for Tobacco Cessation Coding Information. PDF Opens In New Window

Select the appropriate claim form (refer to table below):

Service

Medical and professional services

Hospital inpatient, outpatient, skilled nursing and emergency room services

General dental services

Dental services that are considered medical services (oral surgery, anesthesiology)

Claim form

CMS 1500 Form PDF Opens In New Window

CMS UB-04 Form PDF Opens In New Window

ADA 2002 Claim Form PDF Opens In New Window

CMS 1500 Form PDF Opens In New Window

Claims

Medical

Dental

Refunds

Mail to:

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

Mercy Care
Dental Claims Department
P. O. Box 61235
Phoenix, AZ 85082-1235

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

Electronic submission*

Through Electronic Clearing House

Through Electronic Clearing House

N/A

  1. Instructions on how to fill out the claim forms can be found at the following AHCCCS website addresses:

 

Complete the claim form.

  1. a) 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.
  2. b) 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.

 

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.

  1. a) Electronic clearing house
    Providers who are contracted with Mercy Care 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 we use are:

  • Change Healthcare
  • SPSI
  • SSI

Contact your software vendor directly for questions about your electronic billing.

Contact your provider relations representative for more information about electronic billing.

All electronic submissions shall be submitted in compliance with applicable law including HIPAA regulations and Mercy Care policies and procedures.

  1. b) Through the mail to the appropriate address:

 

Additional information regarding claim submissions can be found in the Provider Manual PDF Opens In New Window under Chapter 16 – Billing, Encounters and Claims.

When the PCP has started medication management services to treat a behavioral health disorder, and it is later determined by the PCP or MC that the member should be transferred to a RBHA prescriber for evaluation and/or continued medication management services, the PCP needs to coordinate the transfer of care.

Please review the Tool Kits on the AHCCCS site for assistance in determining needs of the member:

Sometimes it may be necessary to initiate civil commitment proceedings when due to a member’s mental disorder that person is unable or unwilling to participate in treatment to ensure the safety of the member or the safety of other persons.

In the state of Arizona, individuals can be ordered by the courts to participate in behavioral health treatment if they are found to be:

  1. A danger to themselves
  2. A danger to others
  3. Persistently and Acutely Disabled (PAD), and/or
  4. Gravely Disabled

Definitions

Danger to Self (DTS)
(a) Behavior which, as a result of a mental disorder, constitutes a danger of inflicting serious physical harm upon oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in light of the individual's previous acts, it is substantially supportive of an expectation that the threat will be carried out.
(b) Behavior which, as a result of a mental disorder, will, without hospitalization, result in serious physical harm or serious illness to the person, except that this definition shall not include behavior which establishes only the condition of gravely disabled.

Danger to Others (DTO)
The judgment of a person who has a mental disorder is so impaired that he is unable to understand his need for treatment and, as a result of his mental disorder, his continued behavior can reasonably be expected, on the basis of competent medical opinion, to result in serious physical harm to others.

Persistently or Acutely Disabled (PAD)
A severe mental disorder that meets all the following criteria:
(a) If not treated has a substantial probability of causing the person to suffer or continue to suffer severe and abnormal mental, emotional or physical harm that significantly impairs judgment, reason, behavior or capacity to recognize reality.
(b) Substantially impairs the person's capacity to make an informed decision regarding treatment, and this impairment causes the person to be incapable of understanding and expressing an understanding of the advantages and disadvantages of accepting treatment and understanding and expressing an understanding of the alternatives to the particular treatment offered after the advantages, disadvantages and alternatives are explained to that person.

Gravely Disabled (GD)
A condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or serious illness because he/she is unable to provide for his/her basic physical needs.

Filing A Petition
An Emergent Petition, which is requested by a responsible party when someone is (1) a danger to themselves and/or (2) a danger to others, must be filed in person by a responsible party, at one of the following facilities:

Connections of AZ, 602-416-7600
903 N. 2nd Street, Phoenix
or
Recovery Innovations, 602-650-1212
11361 N. 99th Ave, #402, Peoria

In Pima County:  A Non-Emergent Petition, which is made by a responsible party for an individual, is used when the person is (1) Persistently and Acutely Disabled (PAD) and/or (2) Gravely Disabled.  Someone responsible for the person files the petition.  It can be requested by contacting the Magellan member services department at 1-800-564-5465.