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Effective 03/28/2023, the Mercy Care Provider Manual has been updated. All changes in the manual are highlighted in yellow.
Detailed changes for each chapter are listed below:
Chapter 100 – Mercy Care Provider Manual General Terms
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Section 1.02 – Disclaimer - Additional language added regarding the DCS-CHP website.
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Section 1.04 – Eligibility and PCP Assignment - Added language from AMPM Policy 510-E, per ACOM 416.
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Section 2.00 – Mercy Care Contact Information - Updated the fax number for Claim Disputes and Appeals per NWM.
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Section 4.00 - Provider Responsibilities Overview - Updated this section to include more details regarding Minimum Provisions and Medicaid Regulatory Compliance Addendum.
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Section 4.02 - Appointment Availability Standards - Revised entire section of the manual to match AHCCCS requirements.
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Section 4.06 - Verifying Member Eligibility - Availity information added per recent Provider Notification.
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Section 4.11 - Emergency Services - New paragraph added regarding behavioral health services.
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Section 4.34 - Clinical Guidelines - Paragraph regarding Clinical Guidelines and how they can be sent to providers added by Medical Management.
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Section 4.47 – Availity - Section updated to reflect information on Availity use rather than the Mercy Care Secure portal.
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Section 5.01 - Requirements for EPSDT Providers - Minor language change – behavioral health.
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Section 10.02 - Care Management - Corrected typo.
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Section 14.18 - Payment of Claims - Updated language regarding EFT enrollment.
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Section 14.19 - Claim Resubmission or Reconsideration - Correction made to resubmission attachments received from Network Management. Added Claims Resubmission address per Network Management.
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Section 15.00 - Fraud and Abuse Overview - Updated information for NCQA Requirements to include Member information.
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Section 15.03 - Administrative Remedies for False Claims and Statements - Dollar amounts have been updated per NCQA standards.
Chapter 200 – MCCC, Mercy DD and DCS CHP – Plan Specific Provider Manual
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Section 3.18 – SMI Eligibility Determination - Solari added to this section. Behavioral Health Home added. Contact Guidelines for Children in the Custody of DCS was added.
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Section 3.20 – Out of State Treatment for Behavioral Health - Behavioral Health Home added. Added new link to AMPM Chapter 200.
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Section 3.24 – Mercy Care DCS CHP Psychiatric Acute Care and Behavioral Health Inpatient (BHIF) Services - Outpatient and Inpatient Assessments - New language added.
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Section 3.28 – Housing for Individuals Determined to have Serious Mental Illness (SMI) for Central GSA - Language changes added.
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Section 4.02 – Referral and Intake Process - Language changes regarding Integrated Rapid Response Referrals for Children.
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Section 4.03 – Outreach, Engagement, Reengagement and Closure - Language change to change 12 months to 6 months. Changed language to reflect Behavioral Health Home.
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Section 5.09 - Family Planning Medications and Supplies - Updated Family Planning mailing address.
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Section 5.11 - Request for Non-PDL Drugs - Language changes from our Pharmacy Department.
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Section 6.00 – Peer and Family Support Services and Peer and Family Run Organizations - Language changes from our Peer and Family Support team.
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Section 7.00 - Dental Overview - Updated DentaQuest address.
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Section 7.01 – Dental Covered Services - Updated language regarding AHCCCS directive for AI/AN members.
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Section 8.00 – Grievances - Language updated by Grievance and Appeals team.
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Section 8.02 - Appeals - Updates made to language and fax number.
Chapter 300 – Mercy Care Long Term Care – Plan Specific Provider Manual
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Section 2.00 – MCLTC Overview - Care Manager changed to Case Manager.
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Section 2.01 – MCLTC Program Contractor Changes - Care Manager changed to Case Manager.
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Section 2.05 - Attendant Care Modifiers - Care Manager changed to Case Manager.
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Section 2.06 – Attendant Care Out of Area Care - Care Manager changed to Case Manager.
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Section 2.08 – Electronic Visit Verification (EVV) - Updated information as Non-Provision of Care Log has been replaced by EVV.
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Section 2.09 - Prior Period Coverage for Home and Community Based Services (HCBS) - Care Manager changed to Case Manager.
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Section 2.10 - Case Manager Responsibilities - Care Manager changed to Case Manager.
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Section 2.11 - Service Authorizations - Care Manager changed to Case Manager.
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Section 2.12 – MCLTC Alternative Residential Settings - Care Manager changed to Case Manager.
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Section 2.13 - Provider Requirements for Assisted Living Facilities - Care Manager changed to Case Manager and GCI replaced Wandering Dementia.
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Section 2.14 - Provider Requirements for Adult Foster Care Home - Care Manager changed to Case Manager.
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Section 2.15 - Provider Requirements for Skilled Nursing Facilities (SNFs) - Several language changes made by our Long Term Care team.
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Section 2.17 – Employment Service - New Section added based on Provider Notice.
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Section 3.01 - Covered Services - Care Manager changed to Case Manager.
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Section 3.03 – Long Term Care Services (Covered by DDD) - Added chart for Integrated Care Services covered by Mercy Care versus Long Term Care Services covered by DDD per ACOM 416.
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Section 4.00 - Behavioral Health Overview - Care Manager changed to Case Manager.
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Section 4.06 - Behavioral Health Consults - Care Manager changed to Case Manager. Changed face-to-face meeting to Microsoft Teams or by phone.
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Section 4.08 – Behavioral Analysis Service - Care Manager changed to Case Manager.
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Section 4.15 - Members with Diabetes and the Arizona State Hospital - Care Management changed to Case Management.
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Section 4.16 - Court Ordered Treatment and Petition Process - Care Manager changed to Case Manager and GCI replaced dementia.
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Section 4.17 – SMI Eligibility Determination - Care Manager changed to Case Manager.
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Section 4.26 – Housing for Individuals Determined to have Serious Mental Illness (SMI) - Language changes added.
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Section 5.11 - Request for Non-PDL Drugs - Language change from our Pharmacy Department.
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Section 6.00 – Peer and Family Support Services and Peer and Family Run Organizations - Language changes made.
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Section 7.00 - Dental Services - Updated Dentaquest address. Updated language per AHCCCS directive regarding AI/AN members.
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Section 8.02 - Appeals - New fax number updated.
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Section 8.04 – Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI) - Care Manager changed to Case Manager.
Chapter 400 – Mercy Care RBHA – Plan Specific Provider Manual
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Section 1.00 – About Mercy Care ACC-RBHA - Updated language in this section as to what counties are covered.
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Section 2.02 – Additional Behavioral Health Appointment Availability Information - Minor language change – Behavioral Health Home (BHH).
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Section 2.03 – Referral and Intake Process - Minor language change – Behavioral Health Home (BHH).
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Section 2.04 – Outreach, Engagement, Reengagement and Closure - Minor language change – six months.
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Section 2.06 – Crisis Intervention Services - The Crisis Modifier grid has been added. Access to the Reference Guide has also been added.
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Section 2.09 – Clinical Guidelines - Language changes made.
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Section 2.10 – Serious Mental Illness Decertification - Minor language changes – ACC-RBHA Health Home.
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Section 2.11 – General and Informed Consent - Minor language change – Therapeutic Foster Care (TFC).
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Section 2.12 – SMI Patient Navigator - Minor language change – Health Home.
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Section 2.13 – Pre-Petition Screening, Court Ordered Evaluation, and Court Ordered Treatment - Minor language change – ACC-RBHA Health Home.
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Section 2.14 – Housing for Individuals Determined to have Serious Mental Illness (SMI) - Language changes made.
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Section 3.03 – Case Management Contact Guidelines - Language change made.
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Section 5.02 – Out of State Treatment for Behavioral Health System - Minor language change – Behavioral Health Home.
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Section 6.11 - Request for Non-PDL Drugs - Language changes from our Pharmacy team.
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Section 7.00 – Peer and Family Support Services and Peer and Family Run Organizations - Language changes made by our Peer and Family Support team.
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Section 8.00 – Dental Overview - DentaQuest address updated.
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Section 8.01 – Dental Covered Services - Updated language per AHCCCS directive regarding AI/AN members.
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Section 10.02 – Coordination of Behavioral Health Care with Other Governmental Entities - Language changes made.
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Section 17.04 –Provider Claim Disputes - New fax phone number added.
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Section 18.0 – Provider Requirements for Specific Programs and Services - Updated new or revised PRSPS.
You can access the Mercy Care Provider Manual on our Provider Manual web page for all lines of business by clicking on the link.
As always, don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this Notice and all other provider notices on our Mercy Care website.
Thanks for all you do!
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