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MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMSMercy Care Provider ManualChapter 200 – Mercy Care Complete Care (MCCC)and Mercy Care DD (Mercy DD) – Plan Specific TermsContent highlighted in yellow represents change since the last Provider Manual iteration.MCCC/Mercy DD Chapter 1 – Mercy Care Complete Care and Mercy CareDD Overview1.00 – MCCC and Mercy DD OverviewMCCC/Mercy DD Chapter 2 – Covered and Non-Covered Services2.00 – Coverage Criteria2.01 – Covered Services2.02 – Non-Covered ServicesMCCC/Mercy DD Chapter 3 – Behavioral Health3.00 – Behavioral Health Overview3.01 – Behavioral Health Provider Types3.02 – Alternative Living Arrangements3.03 – Emergency Services3.04 – Behavioral Health Consults3.05 – Behavioral Health Screening3.06 – Behavioral Health Appointment Standards3.07 – Behavioral Health Provider Coordination of Care Responsibilities3.08 – DDD Coordination of Care3.09 – PCP Coordination of Care3.10 – General and Informed Consent3.11 – Family Involvement3.12 – Members with Diabetes and the Arizona State Hospital3.13 – Pre-Petition Screening, Court Ordered Evaluation and Court OrderedTreatment3.14 – Behavioral Health Treatment Plans and Daily DocumentationMercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 1 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMS3.15 – SMI Eligibility Determination3.16 – Reporting of Seclusion and Restraint3.17 – Out of State Treatment for Behavioral Health3.18 – Behavioral Health Assessment and Service Planning Overview3.19 - Assessments3.20 – Minimum Element of the Behavioral Health Assessment3.21 – Provider Submits a Complex Case Request3.22 – Update to Assessment and Service Plan3.23 – Transfer Assessment3.24 – Housing for Individuals Determined to have Serious Mental Illness (SMI)3.25 - Collection of Demographic and Clinical Data TimeframesMCCC/Mercy DD Chapter 4 – General Mental Health/Substance Use(GMH/SU)4.00 – About General Mental Health/Substance Use (GMH/SU)4.01 – Funding4.02 – Referral and Intake Process4.03 – Outreach, Engagement, Reengagement and Closure4.04 – Serious Mental Illness Determination4.05 – Special Populations4.06 – Crisis Intervention Services4.07 – Training RequirementsMCCC/Mercy DD Chapter 5 – Pharmacy Management5.00 – Pharmacy Management Overview5.01 – Updating the Preferred Drug Lists (PDLs)5.02 – Notification of PDL Updates5.03 – Prior Authorization Required5.04 – Over the Counter (OTC) MedicationsMercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 2 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMS5.05 – Generic vs. Brand5.06 – Diabetic Supplies5.07 – Injectable Drugs5.08 – Exclusions5.09 – Family Planning Medications and Supplies5.10 – Behavioral Health Medications5.11 – Request for Non-PDL Drugs5.12 – Discarded Physician-Administered MedicationsMCCC/Mercy DD Chapter 6 – Partnership Requirements with Families andFamily Run Organizations6.00 – Peer and Family Support Services6.01 – Incorporating Peer and Family Voice and Choice in Integrated CareMCCC/Mercy DD Chapter 7 – Dental and Vision Services7.00 – Dental Services7.01 – Dental Covered Services7.02 – Vision ServicesMCCC/Mercy DD Chapter 8 – Grievances, Appeals and Claim Disputes8.00 – Grievances8.01 – Provider Claim Disputes8.02 – Appeals8.03 – Conduct of Investigations Concerning Members with Serious MentalIllness8.04 – Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 3 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMSMCCC/Mercy DD Chapter 1 – Mercy Care Complete Care and Mercy Care DDOverview1.00 – MCCC and Mercy DD OverviewMercy Care Complete Care (herein MCCC) and Mercy Care DD (Mercy DD) , as part of MC, is anot-for-profit partnership sponsored by Dignity Health and Ascension Care Management.MCCC and Mercy DD are committed to promoting and facilitating quality health care serviceswith special concern for the values upheld in Catholic social teaching, and preference for thepoor and persons with special needs. Aetna Medicaid Administrators, LLC administers MCCCand Mercy DD for Dignity Health and Ascension Care Management.MCCC and Mercy DD are managed care organizations that provides health care services topeople in Arizona's Medicaid program. MCCC has held a pre-paid capitated contract with theAHCCCS Administration since 1985. MCCC and Mercy DD provides services to the ArizonaMedicaid populations including: AHCCCS Complete Care: Members select the managed care plan to administer theirbenefits. MCCC is contracted in Maricopa, Pinal and Gila Counties to provide coveredservices to enrolled members and integrates both their behavioral health and physicalhealth needs. Children’s Rehabilitative Services (CRS): Arizona’s Children’s Rehabilitative Services(CRS) program provides medical and behavioral health care, treatment, and relatedsupport services to Arizona Health Care Cost Containment System (AHCCCS) memberswho meet the eligibility criteria and completed the application to be enrolled in the CRSprogram and have been determined eligible. Division of Developmental Disabilities Long Term Care program: Members areenrolled through the Arizona Department of Economic Security/Division ofDevelopmental Disabilities (DDD). DDD is a Medicaid program administered by AHCCCSthrough the Department of Economic Security (DES). MCCC and Mercy DD arecontracted with DDD to provide acute care services. DDD members are in the followingcounties:o Apacheo Cochiseo Coconinoo Gilao Grahamo Greenleeo La Pazo Maricopao MojaveMercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 4 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMS o Navajoo Pimao Pinalo Santa Cruzo Yavapaio YumaGeneral Mental Health and Substance Use (GMH/SU): General Mental Health andSubstance Use (GMH/SU) services are provided to adult members age 18 and older whohave been determined to have an illness in this category. These individuals do not havea serious mental illness. General mental health disorders may include, but are notlimited to, anxiety or depression. Substance use services are also provided for membersusing one or more substances or have a dependency on a substance that causes harm tothemselves or others. Additionally, services are also available for members dealing withboth a general mental health concerns and a substance use at the same time known asco-occurring disorders.KidsCare: AHCCCS offers health insurance through KidsCare for eligible children (underage 19) who are not eligible for other AHCCCS health insurance. For those who qualify,there are monthly premiums. Please review the KidsCare webpage on the AHCCCSwebsite for additional information.Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 5 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMSMCCC/Mercy DD Chapter 2 – Covered and Non-Covered Services2.00 – Coverage CriteriaExcept for emergency care, all covered services must be medically necessary and provided by aprimary care provider or other qualified provider. Benefit limits apply.Each line of business has specific covered and non-covered services. Participating providers arerequired to administer covered and non-covered services to members in accordance with theterms of their contract and member’s benefit package.2.01 - Covered ServicesCovered Services for all members include: Hospital care; Doctor office visits, including specialist visits; Health risk assessments and screenings for members age 21 years of age and over; Laboratory, radiology and medical imaging; Durable medical equipment and supplies’ Medications on MCCC’s list of covered medicines. Members with Medicare will receivetheir medications through Medicare Part D; Emergency care; Care to stabilize you after an emergency; Home health services (such as nursing and home health aide); Nursing home, when used instead of hospitalization, up to 90 days a year; Inpatient rehabilitation services, including occupational, speech and physical therapy; Respiratory therapy; Outpatient Rehabilitation services, including occupational, speech, physical andrespiratory therapy (limitations apply) for patients older than age 21 Routine immunizations; AHCCCS-approved organ and tissue transplants and related prescriptions (limitationsapply); Dialysis; Foot and ankle services; Maternity care (prenatal, labor and delivery, postpartum); Family planning services; Behavioral health services; Medically necessary and emergency transportation. Providers may arrange medicallynecessary non-emergent transportation for MCCC members by calling Member Servicesat 602-263-3000 or 800-624-3879; Medical foods;Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 6 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMS Emergency eye exam and lens post cataract surgery;Urgent care;Hospice;Wellness exams and preventative screenings; andIncontinence briefs to avoid or prevent skin breakdown, with limitations.Additional covered services for children (under age 21): Identification, evaluation and rehabilitation of hearing loss; Medically necessary personal care. This may include help with bathing, toileting,dressing, walking and other activities that the member is unable to do for medicalreasons; Routine preventive dental services, including oral health screenings, cleanings, fluoridetreatments, dental sealant, oral hygiene education, X-rays, fillings, extractions and othertherapeutic and medically necessary procedures; Vision services, including exams and prescriptive lenses (a limited selection of lenses andframes are covered); Outpatient speech, occupational and physical therapy; Chiropractic services; Conscious sedation; Adaptive aids (DD members only); Medically necessary practitioner visits to member’s home (DD members only); Incontinence briefs, with limitations; and Acute services for DDD Members enrolled in CR.Additional services for Qualified Medicare Beneficiaries (QMB): Chiropractic services; Outpatient occupational therapy; and Any services covered by Medicare but not by AHCCCS.Limited and Excluded ServicesThe following services are not covered for adults 21 years and older. (If a member is a QualifiedMedicare Beneficiary, we will continue to pay their Medicare deductible and coinsurance forthese services.)BENEFIT/SERVICESERVICE DESCRIPTIONSERVICE EXCLUSIONS OR LIMITATIONSPercussive vestsThis vest is placed on aperson’s chest and shakes toloosen mucous.AHCCCS will not pay for percussive vests.Supplies, equipment maintenance (care of thevest) and repair of the vest will be paid for.Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 7 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMSBone-anchoredhearing aidCochlear implantLower limbmicroprocessorcontrolled joint/prostheticEmergency dentalserviceTransplantsOccupational andPhysical TherapyA hearing aid that is put on aperson’s bone near the ear bysurgery. This is to carrysound.A small device that is put in aperson’s ear by surgery tohelp you hear better.AHCCCS will not pay for Bone-AnchoredHearing AID (BAHA). Supplies, equipmentmaintenance (care if the hearing aid) andrepair of any parts will be paid for.AHCCCS will not pay for cochlear implants.Supplies, equipment maintenance (care of theimplant) and repair of any parts will be paidfor.A device that replaces aAHCCCS will not pay for a lower limb (leg,missing part of the body andknee or foot) prosthetic that includes auses a computer to help with microprocessor (computer chip) that controlsthe moving of the joint.the joint.Emergency treatment forEmergency dental services are covered forpain, infection, swellingmembers under the age of 21. Coveredand/or injuryemergency dental services for members 21years of age and older are limited to problemfocused exam, required X-rays, jaw fractures,biopsies and medically necessary anesthesia.A transplant is when an organ Approval is based on the medical need and ifor blood cells are moved from the transplant is on the “covered” list. Onlyone person to another.transplants listed by AHCCCS as covered willbe paid for.Exercises taught or providedOutpatient Occupational Therapy services areby a physical therapist tocovered for members under the age of 21,make you stronger or helpwhen medically necessary.improve movementOutpatient Occupational Therapy services arecovered for members, 21 years of age andolder as follows: 15 OT visits per benefit year for restoring askill or level of function and maintainingthat skill or level of function oncerestored, and15 OT visits per benefit year for acquiringa new skill or a new level of function andmaintaining that skill or level of functiononce acquired.Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 8 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMSOutpatient physical therapy visits are limitedto 15 habilitate / 15 rehabilitative for a total of30 visits for the continued care for onediagnosis per contract year (10/1– 9/30).For dual eligible members, the health plan isresponsible for paying the Medicare cost ofshare limited to 15 habilitate/15 rehabilitativefor a total of 30 visits for the continued carefor one diagnosis per contract year (10/109/30).Orthotic DevicesOrthotic devices for members under the age of 21 are provided when prescribed by themember’s primary care provider, attending physician or practitioner.Orthotics devices for members who are 21 years of age and older:MCCC covers orthotic devices for members who are 21 years of age and older when theorthotic is medically necessary as the preferred treatment based on Medicare Guidelines, alongwith the following criteria: The orthotic costs less than all other treatments and surgical procedures to treat thesame condition; and The orthotic is ordered by a physician or primary care practitioner (nurse practitioner orphysician assistant).Repairs or Adjustments of Purchased Equipment:Reasonable repairs or adjustments of purchased equipment are covered for all members overand under the age of 21 to make the equipment serviceable and/or when the repair cost is lessthan renting or purchasing another unit. The component will be replaced if at the timeauthorization is sought and documentation is provided to establish that the component is notoperating effectively.Member HandbookMCCC is responsible for the Member Handbook, available on our Member Handbook webpage.The MCCC Member Handbook applies to ACC members, including GMHSU, non-CMDP and CRS.DDD members also receive the member handbook produced by the contractor who deliverstheir physical health benefits.Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 9 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMSGMHSU members will no longer receive the RBHA handbook, as the benefits for thosemembers may be different. It is also important to note these members may be enrolled in oneof seven health plans, so it is imperative providers ensure the corresponding handbook isoffered to each member.The member handbook is provided to all members in their welcome letter that contains theirmember ID card. MCCC also notifies members annually that they can request a printed copy ofthe member handbook by contacting Mercy Care Member Services.For those members who do not have internet access, please direct them to contact: Mercy Care Member Services at 602-263-3000/800-624-3879 (ACC and DDD physical)Per AHCCCS ACOM Chapter 400, Policy 406 – Member Handbook and Provider Directory,Member Handbooks must be distributed to members receiving services as follows: Provide the Member Handbook to each member/guardian/designated representative orhousehold within 12 Business Days of receipt of notification of the enrollment date tomembers receiving physical health care servicesDocumentation of receipt of the member handbook should be filed in the member’s record, ifgiven to a member by a provider. Member Handbooks will be available and easily accessible on the Mercy Care CompleteCare website (Member Handbook). The Member Handbook is available in English,Spanish, Arabic and Vietnamese. Members receiving healthcare services have the right to request and obtain a MemberHandbook at least annually. MCCC notifies members of their right to request andobtain a Member Handbook at least annually by publishing this information usingnotices or newsletters accessible on MCCC’s website. AHCCCS may require MCCC to revise the Member Handbook and distribute it to allcurrent enrollees if there is a significant program change. AHCCCS determines if achange qualifies as significant.Member Handbooks are reviewed annually, and updated by MCCC sooner, if needed.2.02 – Non-Covered ServicesNon-covered services include: Services from a provider who is NOT contracted with MCCC (unless prior approved bythe Health Plan) Cosmetic services or items; Personal care items such as combs, razors, soap etc.;Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD Plan Specific TermsLast Update: October 2019ProprietaryPage 10 of 141
MERCY CARE COMPLETE CARE PROVIDER MANUALCHAPTER 200 – MERCY CARE COMPLETE CARE –PLAN SPECIFIC TERMS Any service that needs prior authorization that was not prior authorized;Services or items given free of charge, or for which charges are not usually made;Services of special duty nurses, unless medically necessary and prior authorized;Physical therapy that is not medically necessary;Routine circumcisions;Services that are determined to be experimental by the health plan medical director;Abortions and abortion counseling, unless medically necessary, pregnancy is the resultof rape or incest, or if physical illness related to the pregnancy endangers the health ofthe mother;Health services if you are in prison or in a facility for the treatment of tuberculosis;Experimental organ transplants, unless approved by AHCCCS;Sex change operations;Reversal of voluntary sterilization;Medications and supplies without a prescription;Treatment to straighten teeth, unless medically necessary and approved by MCCC;Prescriptions not on our list of covered medications, unless approved by MCCC;Physical exams for qualifying for employment or sports activities;Other Services that are Not Covered for Adults (age 21 and over) Hearing aids, including bone-anchored hearing aids. Cochlear implants; Microprocessor controlled lower limbs and microprocessor-controlled joints for lowerlimbs; Percussive vests; Routine eye examinations for prescriptive lenses or glasses; Routine dental services and emergency dental services, unless related to the treatmentof a medical condition such as acute pain, infection, or fracture of the jaw; Chiropractic services (except for Medicare QMB members);Outpatient speech therapy (except for Medicare QMB members)Mercy Care
MERCY CARE COMPLETE CARE PROVIDER MANUAL CHAPTER 200 – MERCY CARE COMPLETE CARE – PLAN SPECIFIC TERMS . Mercy Care Provider Manual – Chapter 200 – MCCC and Mercy DD - Page . 5. of . 141 . Plan Specific Terms Last Update: October 2019 . Proprietar
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1.00 – About Mercy Care RBHA. Mercy Care RBHA (herein Mercy RBHA), as part of MC, is a not-for-profit partnership sponsored by Dignity Health and Ascension Care Management. Mercy RBHA is committed to promoting and facilitating quality health care services with special concern for the values upheld in
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