Select another plan

Mercy HMO - Central and East Regions

Use this area to learn more about:

Question Answer
Primary Care Physician (PCP) and Referrals
Is a PCP required? No. Selection of a PCP is not required.
If PCP or network provider refers to non-network provider without plan approval, is member responsible for charges? Yes.
If plan authorizes referral to non-network provider for specialty care, what form of authorization is required (written, verbal, etc.)? If a visit to a non-network provider is approved, this is communicated in writing and verbally.
Medicare
If Medicare is primary payor, must member use network providers? No. The member does not need to stay in network. As the secondary payor, the plan only pays up to the Medicare allowed fee. However, if services are received from a non-network provider and are not Medicare eligible, the claim will not be paid by Medicare or the plan.
If Medicare is primary payor, does member need a referral? Referrals are not required.
If Medicare is secondary payor, must member use network providers? Yes.
Accessing Services
List the Nurse Line phone number and hours of operation. 800.811.1187. Available 24 hours a day/7 days a week.
What does the annual vision exam cover in addition to refractions? Eye exam with refraction is covered. Member must select from network ophthalmologists or optometrists.
How is the annual vision exam accessed? Self-refer to network ophthalmologist or optometrist.
How are mental health benefits accessed? If a separate phone number is required for mental health benefits, list the number. Self-refer by calling 314.729.4600 or 800.413.8008.
Which transplant network is used? United Resource Network and Interlink.
How are hearing tests accessed? Self-refer to a network provider.
Flu shots are covered at 100% in a network physician’s office. When a shot is obtained elsewhere, what must the member do to be reimbursed? If a member is unable to obtain a flu shot at a participating provider, submit a copy of the paid receipt and the Take Along form by mail to Mercy Health Plans Member Services Department or fax to 314.214.2463.
How is the per year limit calculated for preventive services such as well-woman exams, annual physicals and mammograms? Once per calendar year or as recommended by nationally recognized preventive guidelines.
Are members allowed access to convenient care clinics? If so, indicate which network is used and the copayment charged. No. Mercy Health Plans does not currently contract with convenient care clinics.
Disease Management Programs: Diabetes, coronary artery disease, congestive heart failure and asthma are covered through MCHCP’s disease management program, Smart Steps®.
Indicate the chronic conditions treated in disease management programs through your medical plan. (Diabetes, coronary artery disease, congestive heart failure and asthma are covered through MCHCP's disease management program, Smart Steps. Smart Steps is not available to members in the South Central and Southwest regions.) Mercy Health Plans Care Management and ExtraCare by ForeSee Health, a Mercy Health Plans Company, provide care coordination for our highest risk members living with complex or multiple chronic diseases such as chronic obstructive pulmonary disease (COPD), high blood pressure, end stage renal disease, hepatitis, multiple sclerosis, rheumatoid arthritis, chronic pain, cancer, seizure disorders and complex pediatric conditions.
What services are available through the disease management programs? Educational mailings related to the chronic condition; health risk assessments; assistance with psychosocial and financial issues; care coordination with a registered nurse care manager; information on wellness and age specific preventive health measures; and collaboration with your physician, treating providers and other care team members.
How are disease management programs accessed? Member can contact member services for information at 866.785.5848 and 314.214.2370.
Special Services
In addition to provider directories, what services can be accessed on your website? Mercy Health Plans general information, Health Headlines, I’m a Member, Your Health and Wellness, and Healthwise® Knowledgebase.
Provide examples of specialized website features available to members only. Online benefit information, graphic surgery, ability to change PCP, request ID cards, change address and change password.
Indicate discounts that are available to members online. Available discounts to members are listed in the member newsletter. Community health events are also found in the member newsletter.
What types of educational programs are available to members? Graphic surgery, Your Health and Wellness, member newsletter listing of events and programs at our participating facilities and in your community. Mercy Health Plans’ Health Education Department can coordinate health fairs and other educational promotions.

Return to top Return to top