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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

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:

CMS 1500 form instructions (PDF): Medical and professional services; dental services considered medical services (oral surgery anesthesiology)
CMS-1450 (UB-04 form) instructions (PDF): Hospital inpatient, outpatient, skilled nursing and emergency room services
ADA 2012 claim form instructions (PDF): General dental services

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.  

You can sign up to receive funds electronically, directly to your bank account. Setting up EFT:

Improves payment consistency

Allows for fast, accurate and secure transaction

Just download the EFT form (PDF). Complete the form (including two authorized signatures). Then, send a voided check or a formal letter from your bank for verification of your account number by:

Email (preferred method)

Fax
Attn: Mercy Care Finance EFT Enrollment
Fax: 1-866-237-0760

We’re not able to accept Aetna EFT forms.

Questions about EFT? Contact us based on the plan.

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

Just download and complete the ERA form (PDF). Then, fax or email it to:

Email (preferred method)

Fax
Attn: Mercy Care ERA Enrollment
1-860-975-3201

Questions about ERA? Contact us at the plan you have questions about.

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: 602-351-2300.

Mail

Mercy Care Grievance and Appeals
4500 E. Cotton Center Blvd.
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.

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.
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.  
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
4500 E. Cotton Center Blvd.
Phoenix, AZ 85040