Claims

Claims Information

Our updated Mercy Care Claims Processing Manual is now available to assist you with any claims or billing questions you may have.     

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

Under Mercy Care

AHCCCS (Arizona Health Care Cost Containment System) is Arizona’s Medicaid Managed Care Program. Mercy Care is contracted with AHCCCS to provide Medicaid covered benefits and services to Mercy Care members. Providers must register with the AHCCCS program to be eligible for payment reimbursement. Registered providers agree to abide by state laws and agree to accept the state Medicaid payment as payment in full. Arizona state law and your Mercy Care provider contract prohibits balance billing MC members for Medicaid covered services and benefits.

Refer to our Provider Manual for more detailed information.

Contracted providers can find reimbursement information in their Mercy Care contracts. Non-contracted providers can refer to the AHCCCS fee schedule for reimbursement information.

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

Medical and professional services

CMS 1500 Form

Hospital inpatient, outpatient, skilled nursing and emergency room services

CMS UB-04 Form 

General dental services

ADA 2012 Claim Form 

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

CMS 1500 Form

 

Claims Mailing Address:

Medical

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

Electronic submission*: Through Electronic Clearing House

Dental Claims Address:  

For All Lines of Business Except Mercy Care RBHA: 

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

For Mercy Care RBHA: 

Mercy Care RBHA Dental Claims
P. O. Box 62978
Phoenix, AZ  85082-2979 

Electronic submission*: Through Electronic Clearing House

Refunds

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

Electronic submission*: N/A

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.

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.

b) Through the mail to the appropriate address:

Additional information regarding claim submissions can be found in the Provider Manual.

A claim dispute is a dispute involving the payment of a claim, denial of a claim, imposition of a sanction or reinsurance. A provider may file a claim dispute based on:

  • Claim Denial
  • Recoupment
  • Dissatisfaction with Claims Payment

Before a provider initiates a claims dispute, the following needs to occur:

  • The claim dispute process should only be used after other attempts to resolve the matter have failed.
  • The provider should contact MC Claims and/or Network Management to seek additional information prior to initiating a claim dispute.
  •  The provider must follow all applicable laws, policies and contractual requirements when filing.
  • According to the Arizona Revised Statute, Arizona Administrative Code and AHCCCS guidelines, all claim 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:

o Within 12 months after the date of service.

o Within 12 months after the date that eligibility is posted.

o Or within 60 days after the date of the denial of a timely claim submission, whichever is later.

 

You may submit your claim dispute in writing through the mail or send electronically to us through fax. Not only do we now have the ability to receive disputes by fax, but we can also respond back to our providers via fax, allowing you to receive faster decisions. If you choose to send via fax, please fax your disputes to 602 351-2300.

Written claim disputes must be submitted to the MC Appeals Department. Please include all supporting documentation with the initial claim dispute submission. The claim dispute must specifically state the factual and legal basis for the relief requested, along with 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.

 

MC will acknowledge a claim dispute request within five (5) business days after receipt. If a provider does not receive an acknowledgement letter within five (5) business days, the provider must contact the Appeals Department. Once received, the claim dispute will be reviewed, and a decision will be rendered within 30 days after receipt. MC may request an extension of up to 45 days, if necessary. If you are submitting via mail, the claim dispute, including all supporting documentation, should be sent to:

 

Mercy Care Grievance System Department

4755 S. 44th Place

Phoenix, AZ 85040

 

If a provider disagrees with the MC Notice of Decision, the provider may request a State Fair Hearing. The request for State Fair Hearing must be filed in writing no later than 30 days after receipt of the Notice of Decision. Please clearly state “State Fair Hearing Request” on your correspondence. All State Fair Hearing Requests must be sent in writing to the follow address:

 

Mercy Care Grievance System Department

Attention: Hearing Coordinator

4755 S. 44th Place

Phoenix, AZ 85040

The EDI vendors that we use are:

  • Change Healthcare
  • SPSI
  • Relay Health

 

Vendor: Southwestern Provider Services (SPSI)

CMS 1500 Payer ID - MCP1

UB-04 Payer ID - MCPU

Contact information:

www.spsi-edi.com

817-684-8500

 

Vendor: Change Healthcare

CMS 1500 and UB-04 Payer ID - 86052

Contact information:

www.changehealthcare.com/

877-363-3666, Option 1 for Sales

Vendor: Relay Health

CMS 1500 and UB-04 Payer ID - 86052

Contact information:

www.relayhealth.com/ 

866-RELAY-ME (866-735-2963 ext. 2)

 

  • 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.
  • Additional information regarding claim submissions can be found in the Provider Manual.

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 Mercy Care member services department at 1-800-564-5465.