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Mercy HMO - South Central and Southwest Regions

Use this area to learn more about:

Question Answer
Primary Care Physician (PCP)
Is a PCP required? Members must choose a PCP.
What is the procedure to change PCP? Contact Member Service and a new ID card is mailed. Member may change PCP and order a new card online.
How often can a member change PCPs? As often as desired.
Can a member choose a network PCP out of the region in which they select a plan? Yes.
What happens if member does not select a PCP? Mercy assigns a PCP to the member.
Can member choose a Nurse Practitioner or Physician Assistant as a PCP? No. The member would be assigned to the PCP who is the collaborating physician for the Nurse Practitioner or Physician Assistant.
Referrals
How does a member obtain a referral? If required, member obtains referral from PCP. Referrals are valid for a specific number of visits and/or days. Based on diagnosis, some referrals may be valid for more than 90 days.
What speciality care does not require a referral other than those listed below?

No referral required to a:

  • network chiropractor for up to 26 visits.
  • network obstetrician or gynecologist for obstetrical or gynecological diagnosis, treatment or referral.
 Referral is not required for annual vision exam at participating ophthalmologist or optometrist.
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 for Medicare primary members.
If Medicare is secondary payor, must member use network providers? Yes.
Accessing Services
List the Nurse Line phone number and hours of operation. 417.820.3182 or 800.330.8305. 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. Member must obtain referral from PCP.
Which transplant network is used? United Resource Network and Interlink.
How are hearing tests accessed? PCP referral to 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 a nationally recognized preventive guideline.
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 Program
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.) Asthma, chronic obstructive pulmonary disease, congestive heart failure and diabetes under the direction of St. John’s Health System.
What services are available through the disease management programs? Multiple services are available dependent on the particular program.
How are disease management programs accessed? Physician referral or self-referral. For further information, contact Utilization Management at 417.820.3182 or 800.330.8305.
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. Discounts available 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. Support group listings are available.

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