Claims Information

The Mercy Care RBHA Claims department is responsible for claims adjudication, resubmissions, claims inquiry/research and provider encounter submissions.  

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

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

Mercy Care RBHA Claims Department

P.O. Box 64835

Phoenix, AZ  85082-4835

 

Mercy Care RBHA (Dental)

P.O. Box 62978

Phoenix, AZ  85082-2978

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

Call our Claims Inquiry/Claims Research department at 800-564-5465 (toll-free), hearing impaired (TDD/TTY) 711

Electronic Claims Submission (EDI)

Electronic Fund Transfer (EFT)

Electronic Remit (ERA)

  • Change Healthcare
  • SPSI
  • Relay Health

For additional information regarding your electronic tools, call your Provider Relations representative at 1-800-564-5465 (TDD/TTY) 711.

 

Vendor: Southwestern Provider Services (SPSI)

CMS 1500 and UB-04 Payer ID - 33628

Contact information:

www.spsi-edi.com

817-684-8500


Vendor: Change Healthcare

CMS 1500 and UB-04 Payer ID - 33628

Contact information:

www.changehealthcare.com/

877-363-3666, Option 1 for Sales


Vendor: Relay Health

CMS 1500 and UB-04 Payer ID - 33628

Contact information:

www.relayhealth.com/ 

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

Mercy Care RBHA is the payer of last resort.  If a member has other insurance, that insurance would be primary. We would require a copy of their explanation of benefits. Per our contract, we follow “lesser of” language when we coordinate benefits.

In accordance with contractual obligations, claims for services provided to a Mercy Care RBHA member must be received in a timely manner. Mercy Care RBHA's timely filing limitations are as follows:

  • New claim submissions: Claims must be filed on a valid claim form within 150 days  from the date services were performed or from the date of eligibility posting, whichever is later, unless there is a contractual exception. For hospital inpatient claims, date of service means the date of discharge of the patient.
  • Claim resubmission: Claim resubmissions must be filed within 365 days from the date of provision of the covered service or eligibility posting deadline, whichever is later. The only exception is, if a claim is recouped, the provider is given an additional 60 days from the recoupment date to resubmit a claim. Please submit any additional documentation that may effectuate a different outcome or decision.

Failure to submit claims in a timely manner could result in your claim being denied for timely filing.  

Additional information regarding claims is available on our Provider Manual web page.