MercyCare Health Plans

(07/14)) booklet

to suggest new policies are encouraged to submit recommendations on the Provider Suggestion (F- (02/09)) form

Coverage Discrepancy Report (F- (09/12)) form. Unless the service does not require other health insurance billing, the

(06/13)) form

Emergency for Non-U.S. Citizens (F- (02/09)) form for clients to take to the local county or tribal agency in their county of

❍ Sterilization claims must be submitted along with a paper Consent for Sterilization (F- (10/08)) form

Providers may submit written inquiries to ForwardHealth by mail using the Written Correspondence Inquiry (F- (07/12))

confidentiality statement as a cover sheet to all faxed PA requests. The Prior Authorization Fax Cover Sheet (F- (12/11))

(F- (02/14)) form sent to providers by the member's certifying agency. The provider's reimbursement is then reduced by

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● A completed PA/RF (Prior Authorization Request Form, F- (05/13)) (or PA/DRF (Prior Authorization/Dental

Services 1, F- (05/13)))

Psychotherapy) Attachment, F- (07/12)) ForwardHealth

Attachment, F- (07/12)) ForwardHealth

Evaluation Attachment, F

for physician-administered drugs, the Portal will prompt a PA/JCA (Prior Authorization/"J" Code Attachment, F- (07/12))

Request Form, F- (07/12)), or PA/HIAS1 (Prior Authorization Request for Hearing Instrument and Audiological

(HealthCheck (07/12))

● A PA/SADTA (Prior Authorization/Substance Abuse Day Treatment Attachment, F- (07/12))

receiving outpatient the first hour for Attachment, F- (07/12))

"Other Services") (07/12))

Providers are required to use the Prior Authorization Amendment Request (F- (07/12)) to amend an approved or modified

Attachment, F- (07/12))

An example of an MUE would be if procedure code (i.e., biopsy of skin lesion) was billed with a quantity of two or more

Sheet (F- (10/08)) must be printed and sent with the attachment to ForwardHealth for processing. Providers must list the

Program Designation of Alternate Prescriber for Restricted Medication Services (F- (12/10)) form and return it to the

An example of a procedure-to-procedure edit would be if procedure codes (i.e., removal of a sweat gland lesion) and

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Provider Appeal (F- (03/09)) form

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Paper adjustment requests must be submitted using the Adjustment/Reconsideration Request (F- (07/12)) form

(07/12)) form

Claim (F- (07/12))

The data alignment requirements do not apply to the Compound Drug Claim (F- (07/12)) and the Noncompound Drug

(07/12)) form

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Data Interchange) Helpdesk or submit a paper (Trading Partner 835 Designation, F- (07/12)) form

of the HITECH Act)

(d) of the HITECH Act, which amends 42 USC s. 1320d-5, and s. 134.97(3), (4) and 146.84, Wis. Stats

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(10/08)). Providers are required to indicate an ACN (attachment control number) for paper attachment(s) submitted with

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For 271 response transactions, Care4Kids enrollment will be identified in the EB segment of the loop. Identified by "MC"

NM1 (name info), N3 (address info), and PER (telephone numbers) segments within the loop

Auburn AL

Madison WI -2969

Madison WI -7850

Madison WI

Madison WI

or enddated the other health Madison WI -0220

Madison WI

Irving TX -9984

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

● Outpatient mental health services (CPT codes

and )

No

No

No

and )

and )

No

and )

No

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

● ESRD (end-stage renal disease)-related services (CPT codes , , )

(i.e., electrocardiogram) were billed on the same claim for the same DOS. Procedure code describes a more

● Health and behavior assessment/intervention (CPT codes , )

● Health and behavior assessment/intervention (CPT codes , )

● Health and behavior assessment/intervention (CPT codes , )

No

● Health and behavior assessment/intervention (CPT codes , )

● Health and behavior assessment/intervention (CPT codes , )

"Other Services")

● Office or other outpatient services (CPT (Current Procedural Terminology) procedure codes

● Office or other outpatient services (CPT (Current Procedural Terminology) procedure codes

● Office or other outpatient services (CPT (Current Procedural Terminology) procedure codes

● Office or other outpatient services (CPT (Current Procedural Terminology) procedure codes

● Office or other outpatient services (CPT (Current Procedural Terminology) procedure codes

● Office or other outpatient services (CPT (Current Procedural Terminology) procedure codes

physician and documented in the same manner as face-to-face services. Coverage is limited to procedure codes or

)

● Office or other outpatient consultations (CPT codes )

● Office or other outpatient consultations (CPT codes )

● Office or other outpatient consultations (CPT codes )

● Office or other outpatient consultations (CPT codes )

● Office or other outpatient consultations (CPT codes )

● Initial inpatient consultations (CPT codes )

● Initial inpatient consultations (CPT codes )

● Initial inpatient consultations (CPT codes )

● Initial inpatient consultations (CPT codes )

● Initial inpatient consultations (CPT codes )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

deduct a copayment for these services (CPT procedure codes and )

In-Home Mental Health/Substance Abuse , ,

No

● Outpatient substance abuse services (HCPCS (Healthcare Common Procedure Coding System) codes

Community Support Program Services

● Outpatient substance abuse services (HCPCS (Healthcare Common Procedure Coding System) codes

Behavioral HF None 303.90-303.91 For individual

Comprehensive Community Services

The originating site is required to submit claims for the facility fee with HCPCS code (Telehealth originating site facility

Crisis Intervention Services

(per diem)

)