Claim Dispute Reminder - October 2022

Applicable To: Mercy Care Complete Care, Mercy Care DD, Mercy Care DCS CHP, Mercy Care Long Term Care and Mercy Care ACC-RBHA 

You may now submit your claim disputes to Mercy Care through email at mercycareappeals@aetna.com or via 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.

All claim disputes must be submitted to the Mercy Care 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 dispute 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.  

It's important to remember that 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 Mercy Care's 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:
• Within 12 months after the date of service.
• Within 12 months after the date that eligibility is posted.
• Or within 60 days after the date of the denial of a timely claim submission, whichever is later.

An appeal is the review of a claim that has been processed and denied or paid incorrectly that the provider would like to dispute. 

The following claims are not considered appeals:

• Voided claims
• Claims submitted under the incorrect health plan (Mercy Care vs. Mercy Care RBHA)
• Claims submitted with omitted information
• Claims submitted with incorrect information
• Resubmissions submitted to the appeals department in lieu of the claims department

All of the above mentioned items are not considered appeals and your submission is being rejected. Additionally the Appeals department will not forward what you submitted to the Claims department. These items will need to be reviewed to ensure eligibility is verified and/or the claims are reviewed and any corrected claims will need to be sent to the correct claims department for reconsideration or resubmission by the provider.

Additionally claims denied for the following reasons are not overturned:

• Claims denied for lack of prior authorization
• Claims denied for appropriate prior authorization (services on claim does not match the services on the prior authorization)
• Claims denied for Timely Filing due to being sent to the incorrect plan (Mercy Care vs. Mercy Care ACC-RBHA)

Although you have the right to appeal, submitting an appeal creates an unnecessary administrative burden on your billing team and the appeals team as these reasons for denials are mandatory regardless of medical necessity. 

For further detail regarding Claim Disputes, please refer to appropriate line of business in our Provider Manual.

Please don't hesitate 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!