April 8, 2019
Provider Manual March 2019 Update

Applicable to: Mercy Care Complete Care, Mercy Care RBHA, Mercy Care Long Term Care, and Division of Developmental Disabilities

Effective 3/27/2019, Mercy Care's Provider Manual has been updated with the below changes: 

We have changed the format of the provider manual, converting it into four separate documents split by chapter as follows:
  • Chapter 100 - Mercy Care Provider Manual - General Terms
  • Chapter 200 - Mercy Care Complete Care Provider Manual - Plan Specific Terms
  • Chapter 300 - Mercy Care Long Term Care Provider Manual - Plan Specific Terms
  • Chapter 400 - Mercy Care RBHA Provider Manual - Plan Specific Terms

The General Terms document contains information that applies to all lines of business. The Plan Specific Terms documents contain information specific to that line of business. We have also added links to help you navigate through the document, based on chapters in each section. 

Detailed changes to each chapter are as follows: 

Chapter 100 – Mercy Care Provider – General Terms
  • Section 2.01 - Provider Credentialing and Contracting for all Plans - Added sections regarding Arizona Regulatory Compliance Addendum and Scope of Work Documents. Updated and linked new AZAHP Credentialing Forms.    
  • Section 4.07 - Preventive or Routine Services - Updated language indicating providers are responsible for preventive care for eligible members and updated Member Handbook links. 
  • Section 4.12 - Controlled Substances Prescription Monitoring Program (CSPMP) - Added specific detail regarding the CSPMP Program and links to register nd review the 2018 ArizonaOpioid Act FAQS. 
  • Section 4.22 - Respecting Member Rights - Added links to the Member Handbooks for each line of business. 
  • Section 4.31 - Clinical Guidelines - Updated links to our Clinical Guidelines web page. 
  • Section 4.36 - Contract Changes or Updates - Updated address and fax numbers. 
  • Section 5.04 - Nutritional Assessment and Nutritional Therapy - Updated Attachment B, AHCCCS Certificate of Medical Necessity for Commercial Oral Nutritional Supplements form reference. 
  • Section 5.09 - Blood Lead Screening - Updated language to reflect new AHCCCS requirements. 
  • Section 6.01 - Integration Initiatives - Added additional language regarding notification requirements when treating for CRS conditions. 
  • Section 6.03 - Who is Eligible for CRS - added our Member Services phone number information. 
  • Section 8.01 - High Risk Maternity Care - Update language regarding high risk maternity care. 
  • Section 8.03 - OB Incentive Program - Clarified OB Incentive Program applies to high-risk pregnancies. 
  • Section 8.04 - Obstetrical Care Appointment Standards - Clarified Postpartum visits language. 
  • Section 8.05 - General Obstetrical Care Requirements - Clarified Postpartum language. 
  • Section 8.06 - Additional Obstetrical Physician and Practitioner Requirements - Updated language per AMPM Chapter 410 regarding CSPMP for pregnant members. 
  • Section 8.08 - Reporting High-Risk and Non-Compliant Behaviors - Reference added to the CSPMP regulatory required program. 
  • Section 11.00 - Care Management and Disease Management Overview - Updated Arizona Opioid Prescribing Guidelines link. 
  • Section 12.00 - Concurrent Review Overview - Updated language regarding continued stay reviews. 
  • Section 12.03 - Physician Medical Review - Clarification regarding medical director review. 
  • Section 16.11 - Bariatric Surgery Criteria - Updated BMI criteria. 
  • Section 16.12 - Pharmacy Prior Authorization - Added section regarding Electronic Prior Authorization (ePA). 
  • Section 17.24 - Skilled Nursing Facilities (SNFs) - Updated Rev Codes for Custodial Level. 
  • Section 17.31 - Program Integrity - Minor language changes. 
  • Section 19.01 - Contract Requirements - Under Seriously Mentally Ill (SMI) Clinics, added section on Mercy - Exclusive Prescriber Program. Also added a section regarding Workforce Development Complaints. 

Chapter 200 – Mercy Care Complete Care Provider Manual – Plan Specific Terms
  • Section 2.01 – Covered Services – Updated Member Handbook language.    

Chapter 300 – Mercy Care Long Term Care Provider Manual – Plan Specific Terms
  • Section 2.13 - Provider Requirements for Assisted Living Facilities – Updated language regarding notice to a resident to terminate placement. 
  • Section 3.01 - Covered Services - Updated Member Handbook language. 
Chapter 400 – Mercy Care RBHA Provider Manual – Plan Specific Terms
  • Section 2.03 – Outreach, Engagement, Reengagement and Closure - Updated information regarding the No Show Policy. Updated information regarding non-ACT adult members being discharged from observation/crisis.   
  • Section 2.04 – Assessment and Service Planning - Moved this section into the Mercy RBHA Provider Manual. 
  • Section 4.00 - Covered and Non-Covered Services - Updated Member Handbook language.    
  • Section 6.00 - Dental Services - Updated age language. 
  • Section 9.00 - Concurrent Review - Updated Behavioral Health Residential Facilities (BHRF) section regarding authorization. 
  • Section 12.02 - Accessing Services with Non-Contracted Providers - Language updated regarding Letter of Agreement Request. Language added for securing services through a non-contracted provider. 
  • Section 12.03 - Accessing Services that Require Prior Authorization - Added to list of Services Requiring Prior Authorization. Added Prior Authorization department fax number. 
  • Section 12.04 - How to Request a Prior Authorization - Several language changes made in this section. 

You can access our Provider Manual on our Provider Manual web page.  All changes to the Provider Manual are highlighted in yellow.

As always, don't hesitate to contact your Mercy Care Provider Relations 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!