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Claims

You can file claims with us electronically or through the mail. We work to streamline the way we process claims. And improve payment turnaround time, so you can save time and effort. 

 

Payment reimbursement

Payment reimbursement

Mercy Care contracts with the Arizona Health Care Cost Containment System (AHCCCS) to provide covered Medicaid benefits and services to members. This is Arizona’s Medicaid Managed Care Program. You’ll need to register with AHCCCS for payment reimbursement. You can learn more about reimbursement in: 

  • Your contract, if you’re a contracted provider 

  • The AHCCCS fee schedule, if you’re a contracted or noncontracted provider 

No balance billing

Balance billing is not allowed. This is when you bill a member for the difference between your charge and the allowed amount. You can read our statements about balance billing:

 

You agree to abide by state laws and accept the state Medicaid payment as payment in full. Arizona state law and your Mercy Care provider contract prohibits the balance billing of members for Medicaid covered services and benefits. Check your provider manual to learn more.

Federal law prohibits balance billing of dually eligible people in the Qualified Medicare Beneficiary (QMB) program, which exempts them from cost-sharing. You must not balance bill QMB members for Medicare cost-sharing, regardless of whether the state reimburses you for the full Medicare cost-sharing amounts. You must accept our Medicare payment and the Medicaid plan payment (if any) as payment in full for Medicare-covered services and benefits. Check your provider manual to learn more.

 

File a claim

File a claim

You’ll need to complete a claim form online or in print. Here are some tips:

  • Complete all required fields and include documentation when necessary. Be sure claims are legible and suitable for imaging and/or microfilming for permanent record retention. 

  • Avoid denials for untimely filing due to illegible or poor-quality copies or missing documentation.

You can also review the instructions for each form:

Don’t send claims by fax or in person. You can submit your completed claim form:

 

You can submit claims or resubmissions online (preferred method) through electronic billing software, which:

  • Ensures faster processing and payment of claims

  • Eliminates the cost of sending paper claims

  • Allows tracking of each claim sent

  • Minimizes clerical data entry errors

  • Results in a Level Two report for your vendor — the only accepted proof of timely filing for electronic claims

Our electronic data interchange (EDI) vendors are:

  • Change Healthcare

  • SPSI

  • SSI

All electronic submissions comply with applicable laws, including HIPAA regulations and Mercy Care policies and procedures.

Questions about electronic billing? Contact us or your EDI vendor for answers. 

Medical claims for Mercy Care ACC-RBHA, DCS CHP, Long Term Care, Developmental Disabilities, and Mercy Care Advantage

Mercy Care Claims Department  
P.O. Box 982975 
El Paso, TX 79998-2975

Medical claims for Mercy Care ACC-RBHA with SMI

Mercy Care ACC-RBHA with SMI Claims Departmentent
P.O. Box 982976
El Paso, TX 79998-2976  

Dental claims 

DentaQuest of Arizona, LLC 
Attention: Claims Department 
P.O. Box 2906 
Milwaukee, WI 53201-2906  

Resubmissions

Mark resubmitted claims clearly with “Attention: Resubmissions” to avoid denial as a duplicate.

 

Per your contract, we need to receive claims for services you provide our members in a timely manner: 

  • New claims: File claims with a valid claim form within 150 days from the date you performed services or from the date of eligibility posting, whichever is later. Do this unless there is a contractual exception. For hospital inpatient claims, date of service means the date of patient’s discharge.

  • Claim resubmissions: File claim resubmissions within 365 days from the date you performed services or eligibility posting deadline, whichever is later. Exception: If a claim is recouped, you have another 60 days from the recoupment date to resubmit a claim. Be sure to include any documentation that may affect the outcome or decision.

If you don’t submit claims in a timely manner, this may result in a denial for timely filing.   

EFT is electronic funds transfer, directly to your bank account. Setting up EFT:

  • Improves payment consistency
  • Allows for fast, accurate and secure transaction

ERA is an electronic file that contains claim payment and remittance info. Setting up ERA:

  • Reduces manual posting of claim payment info, which saves you time and money, while improving efficiency 
  • Removes the need for paper Explanation of Benefits (EOB) statements

We're working with Change Healthcare to give you EFT/ERA Registration Services (EERS). This is a better and more streamlined way for you to access payment services. 

EERS offer a standardized method of electronic payment and remittance while also expediting your enrollment and verification process. 

How does it work?

You'll be able to use the Change Healthcare tool to manage EFT and ERA enrollments and receive transactions from multiple payers on a single platform. Here are some facts about EERS:

  • If your tax identification number (TIN) is active in multiple states, a single registration will auto-enroll you for multiple payers. 
  • You can also complete registration with a national provider identifier (NPI) for payment across multiple accounts. 

Do you currently use Change Healthcare as a clearinghouse? If yes, you’ll still need to complete EERS enrollment.

Do you have an application pending with Change Healthcare? If yes, you don’t need to resubmit it. After enrollment, you’ll get the user guide to help navigate the new system. 

How and when do I enroll?

All our plans will migrate your enrollment and verification to EERS. Your health plan will reach out with state-specific enrollment deadlines. You don’t need to change your EDI vendor to take part in EERS. While signing up for Mercy Care, you’ll be able to sign up for multiple health plans at the same time.

Enroll in EERS.

Questions?

You can visit the Change Healthcare FAQ page. Or contact your Network Management representative.

Find this notice and all other provider notices on our newsletters and notices page.

Was your claim overpaid or paid in error? You can contact us for help by calling Claims Investigation Claims Research at 602-263-3000.

Send any refunds to:

Mercy Care Finance 
P.O. Box 90640 
Phoenix, AZ 85066

 

File a claims dispute

A claims dispute involves the payment of a claim, denial of a claim, imposition of a sanction or reinsurance. You can file a claims dispute based on:

  • Claim denial

  • Recoupment

  • Dissatisfaction with claims payment

Before you begin a claims dispute, take these steps:
 

  • Try to resolve the matter — the claim dispute process is for use when other attempts at resolution have failed.

  • Log in to your Provider Portal to search for your claim.

  • Contact Claims Investigation Claims Research at 602-263-3000. Follow all applicable laws, policies and contractual requirements.

 

All disputes related to a claim for system-covered services must be filed in writing and received by the administration or the prepaid capitated provider or program contractor within one of these time frames:

  • Within 12 months after the date of service

  • Within 12 months after the date that eligibility is posted

  • Within 60 days after the date of the denial of a timely claim submission, whichever is later

These time frames are according to the Arizona Revised Statute, Arizona Administrative Code and AHCCCS guidelines.
 

Mercy Care Advantage providers

Contracted providers with Mercy Care Advantage do not have claim dispute rights. You must submit claims you’re disputing through the resubmission process. 

Federal regulations prohibit us from handling your complaints under the Medicare Advantage appeals process. This is because you are a contracted provider with Mercy Care Advantage.

You can submit your claims dispute by:
 

Fax (preferred method)

We can receive and respond to your dispute by fax, allowing you to get faster decisions: 860-907-3511.

Email

Mail

Mercy Care Grievance and Appeals 
4750 S. 44th Place, Ste. 150
Phoenix, AZ 85040

Be sure to include all supporting documentation with the initial claim dispute submission. The claims dispute must:

  • Specifically state the factual and legal basis for the relief requested

  • Include copies of any supporting documentation, such as remittance advice(s), medical records or claims

Failure to specifically state the factual and legal basis may result in denial of the claim dispute.

  1. We’ll acknowledge a claim dispute request within 5 business days after receipt. If you don’t receive an acknowledgement letter within 5 business days, resend your fax. 

  2. Once received, we’ll review the claim dispute and make a decision within 30 days after receipt. We may ask for an extension of up to 45 days, if necessary.   

  3. If you disagree with our Notice of Decision, you can ask for a State Fair Hearing. You must file the request for a State Fair Hearing in writing no later than 30 days after receipt of the Notice of Decision. Please mark your correspondence “State Fair Hearing Request.” Send it to: 

    Mercy Care Grievances and Appeals
    Attention: Hearing Coordinator 
    4750 S. 44th Place, Ste. 150
    Phoenix, AZ 85040 

 

More about claims

For more information about coordination of benefits, go to your provider manual.

Southwestern Provider Services, Inc. (SPSI)

Phone: 480-652-9665
Email: Bethany Fitzgerald

Payer IDs 
Mercy Care ACC-RBHA with SMI 
CMS 1500 and UB-04: 33628 

All other Mercy Care plans  

  • CMS 1500: MCP1 

  • UB-04: MCPU

Change Healthcare

Phone: 1-877-363-3666, option 1 for Sales 

Payer IDs 
Mercy Care ACC-RBHA with SMI
CMS 1500 and UB-04: 33628 

All other Mercy Care plans
CMS 1500 and UB-04: 86052

Relay Health  

Phone: 1-866-RELAY-ME (1-866-735-2963), ext. 2

Payer IDs 
Mercy Care ACC-RBHA with SMI 
CMS 1500 and UB-04: 33628 

All other Mercy Care plans 
CMS 1500 and UB-04: 86052 

All electronic submissions comply with applicable laws, including HIPAA regulations and Mercy Care policies and procedures.

Questions about electronic billing? Contact us or your EDI vendor for answers. 

Questions?

Refer to your claims processing manual (PDF), check a claim with our IVR system (PDF), or contact us.