Transcription of Mercy Care Provider Manual
1 Mercy Care Provider Manual Visit: Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. Mercy Care Provider Manual . Chapter 100 Mercy Care (MC) - General Terms Content highlighted in yellow represents changes since the last Provider Manual iteration. MC Chapter 1 Introduction to Mercy Care Welcome About Mercy Care Disclaimer MC Policies and Procedures Eligibility Hospital Presumptive Eligibility MC Chapter 2 Mercy Contact Information Mercy Care Contact Information Provider Credentialing and Contracting for all Plans Health Plan Authorization Services Table Community Resources Contact Information Table MC Chapter 3 Provider Relations Overview Provider Relations Overview MC Chapter 4 Provider Responsibilities - Provider Responsibilities Overview AHCCCS Registration Appointment Availability Standards Telephone Accessibility Standards Covering Physicians Locum Tenens Verifying Member Eligibility Preventive or Routine Services Well-Woman Preventative Care Services Provider Requirements Educating
2 Members on their own Heath Care Urgent Care Services Mercy Care Provider Manual Chapter 100 MC - General Terms Page 1 of 206. Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. Emergency Services Controlled Substances Prescription Monitoring Program (CSPMP). Primary Care Providers (PCPs). Specialist Providers Second Opinions Provider Assistance Program for Non-Compliant Members Member's Medical Records Advance Directives - Documenting Member Appointments Missed or Cancelled Appointments Documenting Referrals Respecting Member Rights Consent to Treat Minors or Disabled Members under Guardianship Health Insurance Portability and Accountability Act of 1997 (HIPAA). Cultural Competency, Health Literacy and Linguistic Services Individuals with Disabilities Primary Care Provider (PCP) Assignments Plan Changes Cost Sharing and Coordination of Benefits Copayments Clinical Guidelines Office Administration Changes and Training Requirements Consent Forms Contract Additions or Terminations Continuity of Care Contract Changes or Updates Credentialing/Recredentialing Licensure and Accreditation Contract Enforcement Duty to Report Abuse, Neglect or Exploitation Duty to Warn Marketing Provider Policies and Procedures Health Care Acquired Conditions and Abuse Mercy Care Web Portal Provider Directory Mercy Care Provider Manual Chapter 100 MC - General Terms Page 2 of 206.
3 Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. MC Chapter 5 Early and Periodic Screening, Diagnostic and Treatment (EPSDT). EPSDT Program Overview Requirements for EPSDT Providers Health Education Periodic Screenings Nutritional Assessment and Nutritional Therapy Developmental Screening Tools PCP Application of Fluoride Varnish Pediatric Immunizations/Vaccines for Children Program Body Mass Index (BMI). Blood Lead Screening Eye Examinations and Prescriptive Lenses Hearing/Speech Screening Behavioral Health Screening Dental Screening and Referrals Tuberculin Skin Testing Metabolic Medical Foods Arizona Early Intervention Program MC Chapter 6 Children's Rehabilitative Services (CRS). - Children's Rehabilitative Services (CRS) Overview - Integration Initiatives - CRS Qualifying Medical Conditions - Who is Eligible for CRS.
4 MC Chapter 7 Family Planning Family Planning Overview Provider Responsibilities for Family Planning Services Covered and Non-Covered Services Prior Authorization Requirements MC Chapter 8 Maternity Maternity Overview High-Risk Maternity Care OB Care Management OB Incentive Program Mercy Care Provider Manual Chapter 100 MC - General Terms Page 3 of 206. Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. Obstetrical Care Appointment Standards General Obstetrical Care Requirements Additional Obstetrical Physician and Practitioner Requirements Provider Requirements for Medically Necessary Termination of Pregnancy Reporting High-Risk and Non-Compliant Behaviors Outreach, Education and Community Resources Providing EPSDT Services to Pregnancy Members under Age 21.
5 Loss of AHCCCS Coverage during Pregnancy Pre-Selection of Newborn's PCP. Newborn Notification Process MC Chapter 9 Non-Emergency Transportation Non-Emergency Transportation Covered Services Program Specific Requirements Documentation Requirements Data and Reporting Professional Standards and Responsibilities Vehicle Requirements Performance Improvement Performance Outcome Measures MC Chapter 10 Behavioral Health Assessments and Treatment/Service Planning Behavioral Health Assessments and Service Planning Overview Assessments Minimum Elements of the Behavioral Health Assessment Provider Submits a Complex Case Request Update to Assessment and Service Plan Transfer Assessments MC Chapter 11 Care Management and Disease Management Care Management and Disease Management Overview Referrals Care Management HIV/AIDS.
6 Mercy Care Provider Manual Chapter 100 MC - General Terms Page 4 of 206. Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. High Risk OB. Behavioral Health Disease Management Asthma Chronic Obstructive Pulmonary Disease (COPD). Congestive Heart Failure (CHF). Diabetes Active Health MC Chapter 12 Concurrent Review Concurrent Review Overview MILLIMAN Care Guidelines . Discharge Planning Coordination Physician Medical Review MC Chapter 13 Pharmacy Management Pharmacy Management Overview Updating the Preferred Drug Lists (PDLs). Notification of PDL Updates Prior Authorization Required Over the Counter (OTC) Medications Generic vs. Brand Diabetic Supplies Injectable Drugs Exclusions Family Planning Medications and Supplies Behavioral Health Treatment of Attention Deficit Hyperactivity Disorder (ADHD), Anxiety, Depression and/or Opioid Use Disorder RBHA Covered Services Medication Management Program Request for Non-PDL Drugs Discarded Physician-Administered Medications MC Chapter 14 Quality Management Quality Management Overview Quality Management Plan Quality of Care, Peer Review and Fair Hearing Process Escalation Process Mercy Care Provider Manual Chapter 100 MC - General Terms Page 5 of 206.
7 Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. Ambulatory Medical Record Review Quality Management Studies Data Collection and Reporting Reports Credentialing/Re-Credentialing Streamlining Process Incident, Accident, Death Reporting Processes MC Chapter 15 Partnership Requirements with Families and Family Run Organizations Peer and Family Support Services Incorporating Peer and Family Voice and Choice in Integrated Care MC Chapter 16 Referrals and Authorizations Referral Overview Referring Provider 's Responsibilities Receiving Provider 's Responsibilities Period of Referral Maternity Referrals Ancillary Referrals Member Self-Referrals Prior Authorization Types of Requests Medical Prior Authorization Complex Radiology Service Authorization Bariatric Surgery Criteria Pharmacy Prior Authorization Nutritional Assessment and Nutritional Therapy Metabolic Medical Foods Extensions and Denials Prior Authorization and Referrals for Services Prior Authorization and
8 Coordination of Benefits Prior Authorization Contacts MC Chapter 17 Billing Encounters and Claims Billing Encounters and Claims Overview When to Bill a Member Mercy Care Provider Manual Chapter 100 MC - General Terms Page 6 of 206. Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. Prior Period Coverage Encounter Overview When to File an Encounter How to File an Encounter When to File a Claim Timely Filing of Claim Submissions MC as Secondary Insurer Dual Eligibility MCA Cost Sharing and Coordination of Benefits Injuries due to an Accident How to File a Claim Correct Coding Initiative Correct Coding Incorrect Coding Modifiers Medical Claims Review Checking Status of Claims Payment of Claims Claim Resubmission or Reconsideration Overpayments MC General Claims Payment Information Inpatient Claims Federally Qualified Health Centers (FQHCs).
9 Skilled Nursing Facilities (SNFs). Dental Claims Durable Medical Equipment (DME). Family Planning Claims Complete Obstetrical Package Trimester of Entry into Prenatal Care Provider Remittance Advice Program Integrity MC Chapter 18 Fraud, Waste and Abuse Fraud and Abuse Overview Deficit Reduction Act and False Claims Act Compliance Requirements False Claims Training Requirements Administrative Remedies for False Claims and Statements State Laws Relating to Civil or Criminal Penalties or False Claims and Statements Mercy Care Provider Manual Chapter 100 MC - General Terms Page 7 of 206. Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. MC Chapter 19 Workforce Development General Information Contract Requirements Mercy Care Provider Manual Chapter 100 MC - General Terms Page 8 of 206.
10 Last Updated: March 2019. Proprietary Mercy CARE Provider Manual . CHAPTER 100 GENERAL TERMS. MC Chapter 1 Introduction to Mercy Care - Welcome Welcome to Mercy Care (herein MC)! Our ability to provide excellent service to our members is dependent on the quality of our Provider network. By joining our network, you are helping us serve those Arizonans who need us most. - About Mercy Care MC, when referring to all lines of business, is a not-for-profit partnership sponsored by Dignity Health and Ascension Care Management. MC is committed to promoting and facilitating quality health care services with special concern for the values upheld in Catholic social teaching, and preference for the poor and persons with special needs. Aetna Medicaid Administrators, LLC administers MC for Dignity Health and Ascension Care Management.
