Answers to commonly asked questions

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Where do providers send a claim?
Mercy Care Claims Department
P. O. Box 52089
Phoenix, AZ 85072-2089

Where can providers check claim status or claim remit status? 
Visit MercyOneSource. Here you can check the status of claims, remits and prior authorizations as well as verify member eligibility and more.

How do providers obtain a current Provider Manual or Directory? 
The Find A Provider section of our website is the most current version of our directory. Use it to make referrals to specialists, home health providers and more.

How do I find out who my provider representative is?
Mercy Care assigns every network provider a representative. Provider representatives are in regular contact with providers and/or office staff. You can confirm the name and phone number of your representative by contacting us at 602-263-3000 or 800-624-3879, Express Servce Code 631.

What if the member has insurance other than Medicare? Which fee is used: Mercy Care’s, Medicare’s or the other insurance?
Whichever one is the lowest.

What should I do if it looks like the primary insurance carrier will not be reimbursing me within the 180-day Mercy Care filing limit?
If you believe you will not be paid by the primary carrier within the 180-day Mercy Care filing limit, you may submit a claim to Mercy Care at the same time you submit a claim to the primary carrier. We will deny the initial claim for lack of an Explanation of Benefits (EOB). This allows you up to 12 months* from the date of service to receive payment from the primary payer and resubmit the claim for reconsideration.

*Mercy Care may reconsider payment of claims that have been denied for untimely filing in situations when the provider was making an effort to determine the extent of liability.

Is an authorization number necessary if the member has other insurance?
In most cases, no authorization is required if Mercy Care is the secondary payer. However, if the service is covered by Mercy Care, but is not covered by the primary payer, then an authorization would be required (if the service requires a prior authorization by Mercy Care).

Should providers bill bilateral procedures on one line or two?
Mercy Care follows the same billing procedure as CMS and AHCCCS in regard to bilateral procedures. Providers are to bill bilateral procedures not inherently bilateral on one claim line with a “50” modifier (bilateral service) and one unit on the line.

Example 1:
CPT 69210 is for removal of impacted cerumen, one or both ears. CPT 69210 is inherently bilateral, therefore the code should be submitted on one line only with units = 1.

How should providers bill with multiple modifiers?
If there are multiple modifiers on a single line, they should bill the modifiers together (i.e., 5159; please do not place a space between the modifiers).

How should hospitals bill for outpatient late charges?
The entire claim should be re-billed with the late charges included and clearly marked as a resubmission. We will reverse the original claim and repay the new claim to include the late charges to avoid duplicate denials.

How should providers submit claims for new drugs on the market?
The provider should submit the claim using the appropriate HCPCS code including a copy of the drug invoice that includes the NDC number, drug name and the cost of the drug.

If a member requests a change in their primary care provider, when will the change be effective?
If a member requests a change in their primary care provider, the change to the requested primary care physician becomes effective the first day of the following month.

How do providers obtain authorizations from Mercy Care?
We require prior authorization for selected acute outpatient services and planned hospital admissions. Prior authorization is not required for emergency services. Learn what services require prior authorization.

To request a prior authorization:

  1. Verify member eligibility prior to the provision of services. 
  2. Fully complete appropriate referral/authorization form (OB/GYN, Medical or Pharmacy) and attach supporting documentation. 
  3. Submit request via fax, MercyOneSource or telephone.

Fax numbers:

  • Outpatient Requests & Elective Surgeries: 1-800-217-9345
  • Physical Health Inpatient Hospital: 1-866-300-3926
  • Behavioral Health Inpatient Hospital: 1-855-825-3165
  • Pharmacy: 1-800-854-7614

Questions about covered services, the status of a referral or the need for authorization should be directed to the Prior Authorization department.

How do providers verify enrollment of a member?
You can verify a member’s eligibility at MercyOneSource.

Does Mercy Care offer any disease management programs?
Yes. Disease management programs for asthma, diabetes, COPD and congestive heart failure are available to members. If you would like to make a referral, please contact the disease management staff at 1-866-642-1579.

If a non-contracted primary care physician refers to a contracted specialist, can the specialist see the member and receive payment?
The contracted specialist will be reimbursed for services provided as along as the specialist is contracted and appropriate authorization of services is obtained.

Is Human Papillomavirus (HPV) screening a covered service for women? 
Yes, this is a covered service; providers should follow ACOG guidelines for this screening.

Is the meningitis vaccine covered for members over the age of 18?
Yes, meningitis vaccine is covered.

Do lab tests sent to contracted hospitals require prior authorization?
No, laboratory tests may be sent to contracted hospitals for processing. We encourage providers to send these lab tests to the Mercy Care-contracted clinical laboratory.

What services are covered under Mercy Care?
You can learn more specifics about covered services in the Provider Manual under Covered/Non-Covered Services.

Are providers able to bill under the mother's ID number for newborns?
No, newborns will be assigned their own identification numbers, and claims will need to be billed with the newborn's AHCCCS identification number.

Does Mercy Care offer a perinatal program?
Yes. The objective of Mercy Care’s perinatal program is to:

  • Have every pregnant member begin perinatal care as early as possible
  • Conduct a health risk assessment on every identified pregnant member
  • Coordinate and provide case management services specific to the member's needs
  • Have every pregnant member begin perinatal care as early as possible
  • Conduct a health risk assessment on every identified pregnant member
  • Coordinate and provide case management services specific to the member’s needs

Members who are confirmed to be pregnant are assigned to an OB provider who serves as the member's primary care provider (PCP) throughout the course of pregnancy and for approximately six weeks postpartum.

The pregnant member or her PCP must call Mercy Care at 602-263-3000 or 1-800-624-3879 for an OB provider assignment.

Does Mercy Care have a specific behavioral health release of information form?
Behavioral health providers may utilize their own release of information form.

Can CMS 1500 claims be submitted with date spans?
We do not accept CMS 1500 claims submitted with date spans. Exception: Date spans may be billed if the dates of service are consecutive.
Example: DOS 7/1/13-7/2/13; 99233; 2 units