Member Information

Make the most of your benefits

You want to live the healthiest life you can. And we’re here to help. In addition to your covered benefits, we want you to know about other tools & resources.

Your guide to getting the care you need
If you’re trying to figure out how to get the care and services you need, your Mercy Care Member Handbook can help. In the handbook, you will find:

  • Mercy Care phone numbers
  • Your rights and responsibilities as a member
  • Which services are covered and which are not
  • Information on how to get the care you need
  • How to get help with appointments
  • Tips to keep you healthy

Please take time to read this helpful guide.


Handbook archives:

You can also call Member Services to get a printed Member Handbook. You can reach Member Services at:

  • 602-263-3000 or 1-800-624-3879, Hearing Impaired (TTY/TDD 711)
  • Click on the "Contact Us" link on the Home Page

Looking for an advance directive or other form? You can download any of the forms below at no cost.

Do you need help managing your health?
Sometimes you need some extra help to cope with a health issue. That’s why we offer Case Management.

Not everyone needs a case manager, but those who do, mostly need one for a short time. A case manager can show you how to get services to improve your health. Our goal is to help you learn how to take care of yourself.

If you answer yes to any of these questions, you may want to ask about getting Case Management services.

  • Do you go to the ER a lot?
  • Are you having a hard time getting your medication or supplies that your doctor ordered?
  • Do you need help getting on the Arizona Long Term Care System?
  • Do you have HIV?
  • Do you have medical conditions, such as high blood pressure, diabetes, asthma and congestive heart disease, that don’t get better with medication?
  • Do you not know why your primary care doctor is sending you to a specialist provider?
  • Are you pregnant and having problems?
  • Are you a pregnant teenager?
  • Are you pregnant and over 35 years old?
  • Did you have a baby born too early?

If you answered yes, you can ask your doctor to refer you for Case Management services. You can also call Mercy Care Plan directly. A nurse will look at your request and decide if you need to meet with a case manager.

If you have one of the following medical conditions:  depression, high blood pressure, diabetes, asthma or congestive heart disease, please contact us so we can help you take care of your disease.

To request a medical case manager, please call: 602-453-8391

To request a case manager during your pregnancy, please call: 602-798-2703

If you are a Mercy Care Advantage member, and you would like to request a case manager please call: 602-586-1870. You can call 8 a.m. - 5 p.m., Monday through Friday.

Information for our Children's Rehabilitative Services (CRS) members
The Children’s Rehabilitative Services program has been serving children with special health care needs since 1929. This program provides health care and support services to individuals who have certain chronic or disabling conditions.

Members have access to a statewide network of providers in a number of settings. Members can get care and services in a clinic or in a clinic-like setting such as a field clinic or through telemedicine. In a field clinic, a provider travels to an identified area of the state to provide services. Providers can also use telemedicine equipment to provide care by video to rural areas. Pharmacies, labs and diagnostic services are available to members in clinics or close to their own communities.

Who Is Eligible for CRS?
To be eligible for CRS services, you must:

  • Have a CRS eligible diagnosis
  • Be a U.S. citizen or qualified resident
  • Live in Arizona
  • Be enrolled in AHCCCS
  • Be under the age of 21 at the time of initial enrollment, and
  • Require multi-specialty physician services

 
What happens if you have a CRS diagnosis?
*Our Mercy Care CRS Liaison will obtain the needed medical records and send a referral to the AHCCCS CRS Enrollment Unit.
*If enrolled into CRS, you will have a CRS designation and all your care will be provided by Mercy Care. Including, but not limited to:

  • Case management
  • Primary care services
  • Behavioral health services
  • Home health specialty services
  • Durable Medical Equipment (DME) services


CRS Multi-Specialty Interdisciplinary Clinics (MSICs)
A Multi-Specialty Interdisciplinary Clinic (MSIC) is your (or your child’s) assigned health home. This is one location where a CRS member can see all of their medical specialists, benefit from community involvement and receive support services. At the MSIC, you and your family can meet face-to-face with your care team to get medical care, behavioral health care services and be a part of your care plan development.

Each MSIC is open Monday through Friday from 8 a.m. to 5 p.m. You will receive a welcome call from a Care Management team member to tell you more about CRS benefits and help you schedule your first CRS appointment.

CRS MSICs are at the following locations:

DMG Children’s Rehabilitative Services
3141 North 3rd Ave.
Phoenix, AZ 85013
602-914-1520
1-855-598-1871
https://www.dmgcrs.org


Children’s Clinics
Square & Compass Building
2600 North Wyatt Dr.
Tucson, AZ 85712
520-324-5437
1-800-231-8261
https://www.childrensclinics.org 


Children’s Rehabilitative Services
1200 North Beaver St.
Flagstaff, AZ 86001
928-773-2054
1-800-232-1018
https://nahealth.com/childrens-health-center/kids-special-healthcare-needs


Children’s Rehabilitative Services
Tuscany Medical Plaza
2851 South Ave. B
Building 25 #2504
Yuma, AZ 85364
928-336-7095
1-800-837-7309
https://www.yumaregional.org/Medical-Services/Pediatric-Care/Pediatric-Sub-Speciality-Clinic/Children-s-Rehabilitation-Services


CRS care team
The CRS Program uses a team approach to provide your care. Exactly who will be on your team depends on your special health care needs. Get to know who is on your team so you can talk to them about your care and services. Health providers on your team could be:

Surgeons:

  • Cardiovascular and thoracic surgeons
  • General pediatric surgeons
  • Ear, Nose and Throat (ENT) surgeons
  • Neurosurgeons
  • Ophthalmology surgeons
  • Orthopedic surgeons (general, hand, scoliosis, amputee)
  • Plastic surgeons

Medical specialists:

  • Cardiologists
  • Neurologists
  • Rheumatologists
  • General Pediatricians
  • Geneticists
  • Urologists
  • Primary Care Providers

Behavioral health care providers and services:

  • Psychiatrists
  • Psychologists
  • Residential Care Facilities
  • Peer Support
  • Crisis Services
  • Inpatient Services
  • Counseling (Individual, Family, Group)
  • Child and Family Team
  • Behavioral Health Day Program
  • Community Mental Health Centers
  • Substance Abuse (Assessment, Counseling, Medication Therapy)

Dental providers:

  • Dentists
  • Orthodontists
  • Dental Hygienists

You can invite others to be on your team if you would like. Talk to your specialty clinic nurse to find out how to invite someone to be on your tem.


Can I stay in CRS after age 21?
Enrolled CRS members will lose their CRS designation the month of their 21st birthday. However, your providers and care will not change. Mercy Care will continue to be your AHCCCS Plan for all of your healthcare needs.

If you have questions about your CRS benefits or services, you can call Member Services Monday through Friday from 7 a.m. to 6 p.m. Monday through Friday at 602-263-3000 or 1-800-624-3879 (TTY/TDD 711).

Mercy Care reports our health plan's quality scores and related information, as required by our contract with AHCCCS.

AHCCCS Acute Member Survey Results and Health Plan Report Card 

2012 AHCCCS Health Plan Report Card

All Survey Information

 

 

A hospital stay is a transition from your usual every day care. Although going to the hospital can be stressful, you can take steps to prepare. If you require a hospital stay, we hope this flyer will help you and your caregivers prepare. English (English | Español | العربية |Tiếng Việt)

If you disagree with our decision described in the Notice of Adverse Benefit Determination letter, you have the right to request an appeal. An appeal is a formal procedure asking us to review the request again and confirm if our original decision was correct. During this process, you may submit additional supporting documents or information that you believe would support a different outcome and decision.

You, your representative, or a provider acting with your written permission, may request an appeal with us. The appeal must be submitted within 60 calendar days from the date on your Notice of Adverse Benefit Determination letter. The appeal may be submitted in writing or by telephone. If you need an interpreter, one will be provided. We will not retaliate against you or your provider for filing an appeal.

To file an appeal, you must mail, call or fax the request using the following:

Mercy Care
Appeals Department
4350 E Cotton Center Blvd.
Building D
Phoenix, AZ 85040

Phone: 602-453-6098 or 1-800-624-3879
Fax: 602-230-4503

 

Request for Standard Appeal
When we get your appeal, we will send you a letter within five (5) calendar days. This letter will let you know that we got your appeal and how you can give us more information. If you are appealing services that you want to continue while your case is reviewed, you must file your appeal no later than 10 calendar days from the date on the Notice of Adverse Benefit Determination letter.

In most cases, we will resolve your appeal within 30 calendar days. Sometimes, we might need more information to make a decision. When this occurs and we believe it is in your best interest, we will request an extension on your appeal. An extension allows an additional 14 calendar days to complete our review and make a decision. If we ask for an extension, we will mail you a written notice explaining this and tell you what information we need still need. If we don’t receive the additional information within this timeframe, we may deny the appeal. You may also request a 14 calendar day extension if you need more time to gather information for the appeal.

Once we have completed the review of your appeal, we will send you a letter with our decision. The letter tells you about our decision and explains how it was made. If we deny your appeal, you may request that AHCCCS look at our decision through a State Fair Hearing. You can request this next step by following the directions we provide in the decision letter.

If you request a State Fari Hearing, you will receive information from AHCCCS about what to do. We will forward your appeal file and related documentation to AHCCCS at the Office of Administrative Legal Services.

If after the State Fair Hearing, AHCCCS will make a decision. If they find that our decision to deny your appeal was correct, you may be responsible for payment of the services you received while your appeal was being reviewed. If AHCCCS decides that our decision on your appeal was incorrect, we will authorize and provide the services promptly.


Members enrolled in DD must file their appeal with the Division of Developmental Disabilities Compliance and Review Unit within 60 days of the date of the action, decision or incident with which they were unhappy. Appeals may be phoned in or mailed to the following address:

Department of Economic Security
Division of Developmental Disabilities
Compliance and Review Unit, Site Code 791A
1789 W. Jefferson, 4th Floor
Phoenix, AZ 85007

1‑800‑624‑4964

The Division of Developmental Disabilities Compliance and Review Unit will investigate the appeal and make a decision. A letter will be mailed to you stating the decision, the reason for the decision and the way you may request a fair hearing with AHCCCS if you are still not happy.


Request for expedited resolution
You or your representative can request an expedited resolution to your appeal if you believe that the timeframe of a standard resolution might jeopardize your life, health or ability to attain, maintain or regain maximum function. We may ask you to send us supporting documentation from your provider. If your provider agrees, we will expedite the resolution of your appeal. We will also automatically expedite the resolution of your appeal if we believe following the standard resolution process could jeopardize your life or health.

If we request that you send us supporting documentation from your provider but do not receive it, your appeal will be resolved within 30 calendar days. When we decide not to expedite the resolution of your appeal, we will notify you promptly. We will attempt to call you and will mail you a written notice within two (2) calendar days that explains this outcome. For more information, please see Request for Standard Appeal in this handbook.

When we expedite the resolution of your appeal, we will resolve your appeal within three (3) business days. Sometimes, we may need more information to make a decision. When this occurs and we believe it is in your best interest, we will request extension on your appeal. An extension allows an additional 14 calendar days to complete our review and make a decision. If we ask for an extension, we will mail you a written notice explaining this and tell you what information we need still need. If we don’t receive the additional information within this timeframe, we may deny the appeal. You may also request a 14 calendar day extension if you need more time to gather information for the appeal.

Once we have completed the review your appeal, we will send you a letter with our decision. The letter tells you our decision and explains how it was made. If we deny your appeal, you may request for AHCCCS to review our decision through a State Fair Hearing. You can request this next step by following the directions we provide in the decision letter.

If you request a State Fair Hearing, you will receive information from AHCCCS about what to do. We will forward your appeal file and related documentation to AHCCCS at the Office of Administrative Legal Services.

After the State Fair Hearing, AHCCCS will make a decision. If they find that our decision to deny your appeal was correct, you may be responsible for payment of the services you received while your appeal was being reviewed. If AHCCCS decides that our decision on your appeal was incorrect, we will authorize and provide the services promptly.

DD members should file their request for expedited resolution directly with Mercy Care.


Quick tips about denial, reduction, suspension or termination of services and appeals

  • You will get a letter (Notice of Adverse Benefit Determination) when a service has been denied or changed.
  • If you want to ask for a review (appeal) of Mercy Care Plan’s action, follow the directions in your notification letter.
  • To request that services be continued, you must file your appeal no later than 10 days from the date of your notification letter, or within the time frame listed in the notification letter.

A grievance is any expression of dissatisfaction related to the delivery of your health care that is not defined as an appeal. This is also called a complaint. You may have a problem with a doctor or felt that office staff treated you poorly. You may have received a bill from your specialist or had difficulty reaching the transportation company for your ride home. A grievance might include concerns with the quality of the medical care you received. Please let us know if you have a concern like this or need help with another problem. The fastest way to report a grievance is to call Member Services at 602-263-3000 or  1-800-624-3879 (TTY/TDD 1-866-602-1982).

A representative will document your grievance. It is important to provide as much detail as possible. The representative will explain the grievance resolution process and answer any other questions you may have. We may also need to call you back to provide updates or ask you for more information. We want to ensure that you are receiving the care and services you need.

If you prefer to file your grievance in writing, please send your complaint to:

Mercy Care
Grievance Department
4350 E Cotton Center Blvd.
Building D
Phoenix, AZ 85040


Filing a grievance will not affect your future health care or the availability of services. We want to know about your concerns so we can improve the services that we offer.

  • When you call to report a grievance, we will try to help resolve any concerns you have right away. If you submit your grievance in writing, we will send you a letter within five (5) calendar days. The letter acknowledges our receipt of your grievance and explains how you will be notified of the resolution.
  • If you submit a grievance by telephone, we may be able to resolve your concerns and tell you the resolution during the call.
  • If your grievance involves concerns about the quality of care or medical treatment you received, we will send the case to our Quality Management department.
  • When we cannot resolve your grievance right away, we will let you know and explain the next steps. During our investigation of your concerns, we will work with other departments at Mercy Care as well as your health care provider(s).
  • During our investigation, we may need to speak with you again. We may have more questions or we may want to confirm that your immediate needs are met.
  • Once the review of your grievance is complete, we will notify you of the resolution.
  • If your grievance was reviewed by our Quality Management department, you will get the resolution in writing.
  • For other cases, we will call you and explain the resolution to your grievance. If we are unable to reach you, we will send the resolution in writing.
  • We are committed to resolving your concerns as quickly as possible and in no more than 90 days from the date you submitted your grievance.

As a Mercy Care member, you have rights and responsibilities. These rights are listed below. It is important that you read and understand each one. If you have questions, please call Mercy Care Member Services.

 

Your rights as a member

  • The name of your PCP and/or case manager.
  • A copy of the Mercy Care Member Handbook, which includes a description of covered services.
  • How Mercy Care provides after hours and emergency care.
  • The right to file a complaint about Mercy Care.
  • The right to request information about the structure and operations of Mercy Care or their subcontractors.
  • How Mercy Care pays providers, controls costs and uses services. This information includes whether or not Mercy Care has Physician Incentive Plans (PIP) and a description of the PIP.
  • The right to know whether stop‑loss insurance is required.
  • General grievance results and a summary of member survey results.
  • Your costs to get services or treatments that are not covered by Mercy Care.
  • How to get services, including services requiring authorization.
  • How Mercy Care evaluates new technology to include as a covered service.
  • Changes to your services or what actions to take when your PCP leaves Mercy Care.
  • You have the right to be treated fairly and get covered services without concern about race, ethnicity, national origin (to include those with limited English proficiency), religion, gender, age, mental or physical disability, sexual orientation, genetic information or ability to pay or speak English. Confidentiality and privacy
  • You have a right to privacy and confidentiality of your health care information.
  • You have a right to talk to health care professionals privately.
  • You will find a copy of the “Privacy Rights” notice in your welcome packet. The notice has information on ways Mercy Care uses your records, which includes information on your health plan activities and payments for services. Your health care information will be kept private and confidential. It will be given out only with your permission or if the law allows it.Treatment decisions
  • You have the right to agree to, or refuse, treatment and to choose other treatment options available to you. You can get this information in a way that helps your understanding and is appropriate to your medical condition.
  • You can choose a Mercy Care PCP to coordinate your health care.
  • You can change your PCP.
  • You can talk with your PCP to get complete and current information about your health care and condition. This will help you and/or your family understand your condition and be a part of making decisions about your health care.
  • Within the limits of applicable regulations, Mercy Care staff may help manage your health care by working with you, community and state agencies, schools, and your doctor.
  • You have the right to information on which procedures you will have and who will perform them.
  • You have the right to a second opinion from a qualified health care professional within the network. You can get a second opinion arranged outside of the network, at no cost to you, only if there is not adequate in‑network coverage.
  • You have the right to know treatment choices or types of care available to you and the benefits and/or drawbacks of each choice.
  • You can decide who you want to be with you for treatments and exams.
  • You can have a female in the room for breast and pelvic exams.
  • Your eligibility or medical care does not depend on your agreement to follow a treatment plan. You can say “no” to treatment, services or PCPs. You will be informed about what may happen to your health if you do not have the treatment.
  • Mercy Care will tell you in writing when any health care services requested by your PCP are reduced, suspended, terminated or denied. You must follow the instructions in the notification letter sent to you.
  • You have the right to be provided with information about creating advance directives. Advance directives tell others how to make medical decisions for you if you are not able to make them for yourself. Medical records requests
  • At no cost to you, you have the right to annually request and receive one copy of your medical records and/or inspect your medical records. You may not be able to get a copy of medical records if the record includes any of the following information: psychotherapy notes put together for a civil, criminal or administrative action; protected health information that is subject to the Federal Clinical Laboratory Improvements Amendments of 1988; or protected health information that is exempt due to federal codes of regulation.

 

  • Mercy Care will reply to your request within 30 days. Mercy Care’s reply will include a copy of the requested record or a letter denying the request. The written denial letter will include the basis for the denial and information on ways to get the denial reviewed.

 

  • You have the right to request an amendment to your medical records. Mercy Care may ask that you put this request in writing. If the amendment is made, whole or in part, we will take all steps necessary to do this in a timely manner and let you know about changes that are made.

 

  • Mercy Care has the right to deny your request to amend your medical records. If the request is denied, whole or in part, then Mercy Care will provide you with a written denial within 60 days. The written denial includes the basis for the denial, notification of your right to submit a written statement disagreeing with the denial and how to file the statement.

 

Reporting your concerns

  • Tell Mercy Care about any complaints or issues you have with your health care services.
  • You may file an appeal with Mercy Care and get a decision in a reasonable amount of time.
  • You can give Mercy Care suggestions about changes to policies and services.
  • You have the right to complain about Mercy Care. Personal rights
  • You have the right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
  • You have the right to receive information on beneficiary and plan information. Respect and dignity
  • You have the right to be treated with respect and with due consideration for your dignity and privacy.
  • You have the right to participate in decisions regarding your health care, including the right to refuse treatment.
  • You can get quality medical services that support your personal beliefs, medical condition and background. You can get these services in a language you understand. You have the right to know about other providers who speak languages other than English.
  • You can get interpretation services if you do not speak English. Sign language services are available if you are deaf or have difficulty hearing. You may ask for materials in other formats or languages from Mercy Care Member Services.
  • The type of information about your treatment is available to you in a way that helps your understanding given your medical condition.

Members who are part of Division of Developmental Disabilities

  • You have the right to get a replacement caregiver for “critical services” within two hours.



Emergency care and specialty services

  • You can get emergency health care services without the approval of your PCP or Mercy Care when you have a medical emergency. You may go to any hospital emergency room or other setting for emergency care.
  • You may get behavioral health services without the approval of your PCP or Mercy Care.
  • You can see a specialist with a referral from your PCP.
  • You can refuse care from a doctor you were referred to, and you can ask for a different doctor.
  • You may request a second opinion from another Mercy Care doctor.

Fraud
Committing fraud or abuse is against the law. Your health benefits are given to you based on your health and financial status. You should not share your benefits with anyone. If you misuse your benefits, you could lose your AHCCCS benefits. AHCCCS may also take legal action against you. If you think a person, member or provider is misusing the program, please call Mercy Care Plan Member Services or AHCCCS.

Fraud and abuse also means loaning, selling or giving your member ID card to someone, inappropriate billing by a provider or any action intended to defraud the AHCCCS program.

Fraud is a dishonest act done on purpose.

Examples of member fraud are:
- Letting someone else use your Mercy Care Plan ID card
- Getting prescriptions with the idea of abusing or selling drugs
- Changing information on your Mercy Care Plan ID card
- Changing information on a prescription

Abuse
Abuse can mean providers that take actions resulting in needless costs to AHCCCS. This includes providing medical services that are not required. It may also mean the provider does not meet required health care standards. Abuse can also include member actions that result in extra cost to AHCCCS.

Abuse means provider practices that are inconsistent with sound financial, business, or medical practices. This can result in an unnecessary cost to the Medicaid program. Abuse can also be a refund for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes member practices that result in unnecessary cost to the Medicaid program.

 

Reporting
If you think a person, member or provider is misusing the program, please let us know.

Mercy Care Plan Fraud Hotline: 1‑800‑810‑6544

AHCCCS Fraud Reporting: 602‑417‑4193 or 1‑888‑487‑6686

If you would like a printed copy of the Member Handbook or Provider Directory, call Member Services at:

  • 602-263-3000 or 1-800-624-3879 (TTY/TDD 711)
  • Click on the "Contact Us" link on the Home Page