Urgent Care

Urgent Care is care you need sooner than a routine doctor's office visit. Urgent Care is not Emergency Care. Some examples of urgent care cases are: minor cuts, non-severe bleeding, sprains, bruises, minor burns, and most drug reactions. If you are in your network Service Area, Urgent Care is covered at any participating provider or participating Urgent Care Center. Network Urgent Care Centers are listed in your Provider Directory. If you are out of your Network Service Area and cannot return home without medical complications or harm, you should seek care from the nearest urgent care facility (physician, clinic, hospital). Follow up care is not covered when it is provided by a non-MercyCare Provider.

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Emergency Care

Emergency means a medical condition that manifests with symptoms of sufficient severity, including pain, to lead a prudent lay person to reasonably conclude that a lack of immediate medical attention will likely result in death or serious injury to your body or if you are pregnant, serious jeopardy to the fetus.

Some examples of emergency care cases are: heart attacks, chest pain, strokes, loss of consciousness, significant blood loss, suffocation, attempted suicide, seizure or convulsions, acute allergic reactions, acute asthma attacks, acute appendicitis, coma, or drug overdoses.

If, as a prudent lay person, you reasonably conclude that a lack of immediate medical attention will likely result in bodily injury or harm, go to the nearest emergency care provider or call 911. You or your family must notify MercyCare Insurance Company as soon as reasonably possible or within 48 hours of an emergency or out of state emergency hospital admission. MercyCare has the right to transfer you (at no expense to you) to the facility of their choice upon confirmation from your attending physician that you are able to travel. As an HMO member your initial visit to an emergency facility is covered. A participating network practitioner or provider must provide follow up care. Follow up care received from a non-participating provider is not a covered benefit.

Life threatening emergencies are covered anywhere in the world, however providers outside the United States may not accept insurance payments and may require you to provide payment. Re-imbursement for covered benefits can be arranged when you return to the service area.

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Out of Plan Referrals

MercyCare has an extensive network of participating providers and specialists. If the specialty care your participating MeryCare Primary Care Physician wants you to receive is available within MercyCare's provider network, he or she will generally direct you to a specialist in the network. MercyCare does not require pre-approved referrals to specialists within your provider network. If medically necessary care is not available from a network provider, your primary care physician or another network practitioner may submit a referral for services from an out-of-network provider.

• A referral is a written form prepared by a participating Mercy Care practitioner requesting approval for you to receive services from an out-of-network provider. 
• Non-urgent referral requests must be submitted in writing to MercyCare before you receive services from an out of network provider. If care is obtained without an approved referral, you will be responsible for the charges. 
• Once MercyCare makes a decision on the referral, MercyCare will notify you, the requesting practitioner, and the out of plan provider. 
• Approved notices will state the type or extent of services authorized and the time period that the referral is valid. 
• Denial notices will state the reason for the denial, redirect you to available network services and provide grievance and Independent Review information. 
•  A referral is not required for emergency care when you are out of your network service area.
• Call Customer Service at 1-800-895-2421 if you have questions about a referral.

Please be advised that it is your responsibility to confirm that MercyCare has authorized a referral before you receive services. If you receive care from an out of network provider without a MCIC approved referral, you will be held financially responsible for that provider's charges.

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Services Denied

When a service has been denied by the MercyCare Quality Health Management Department, the referring or requesting physician will be notified in writing of the decision. The letter will explain the reason for the denial, the criteria the decision was based on, and alternative options for treatment. Also included in the notice is a phone number for the referring provider to contact the reviewing physician at MercyCare Health Plans. The notice will also contain Grievance and Independent Review Information. You may request a copy of the policy, certificate of coverage, schedule of benefits, clinical criteria, or expert opinion the decision was based on.

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 Utilization Management Decision Determinations

Utilization management decisions are to be determined by qualified licensed health professionals in a fair, impartial, and consistent manner. A licensed physician, behavioral health practitioner, or pharmacist will review any requests for services that are denied as not medically necessary.

Utilization management decisions will be based on:

• The member's certificate of coverage
• The member's schedule of benefits
• The member's primary care physician or attending physician's medical documentation
• McKesson InterQual® Clinical Decision Criteria (inpatient and outpatient medical, surgical, and behavioral health services)
• Hayes® Medical Technology Directory
• MercyCare Health Plan's policies for specific procedures
• Assessment of the availability of services in the member's provider network

In cases where the clinical judgment needed for utilization management decisions is sufficiently specialized, MercyCare will use board certified experts of similar specialty to assist in making the utilization management decision.

You may request a copy of the policy, certificate of coverage, schedule of benefits, or expert opinion the utilization management decision is based on.

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New Technology

MercyCare Insurance Company evaluates new and existing technologies for possible inclusion in your benefit package.

New technology can be a service, treatment, procedure, treatment facility, equipment, drug, device or supply.

Health care determinations are based on expert opinion, however your benefit package may have exclusions for certain types of services or procedures.

Some of the criteria that may be used for evaluation of new technologies are:

• Whether it is commonly performed or used on a widespread geographic basis
• If the service is generally accepted by the medical profession in the Unites States of America to treat a specific bodily injury or sickness
• The failure rate or side effect of the technology is acceptable
• The technology is recognized for reimbursement by Medicare, Medicaid and other insurers and self-funded plans

The Hayes® Medical Technology Directory is one of the sources used by MercyCare as an aid in developing coverage determinations that are based on scientific evidence and proven to be safe and effective. Your member newsletter will contain or your network provider will receive notification of new technology that is approved for the membership by MercyCare.

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MercyCare Quality Health Management Staff Availability

If you or your practitioner has any questions about your utilization management decisions or coverage determinations, please call MercyCare's customer service department at (800) 895-2421. TTY users may call 1-800-947-3529 for assistance.

The Quality Health Management staff is available to assist you Monday through Friday, 8:00am to 4:30 pm. After 4:30 pm and on holidays and weekends, you may still call the toll-free number and leave a message on confidential voice mail.

The appropriate staff person will respond during the next business day. Please feel free to call MercyCare with any questions or concerns.

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Pricing

While quality of services delivered and safety are important, you may also want access to hospital pricing.  The Wisconsin Hospital Association (WHA) Information Center created PricePoint to give consumers access to this information.  This website allows consumers to obtain information about any type of hospitalization and selected outpatient procedures. 

You can access information from PricePoint at www.wipricepoint.org.

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