State of Wisconsin Members
Thank you for visiting the MercyCare Health Plans website. We hope you will find our site to have the information and direction you need to properly manage your health care.
MercyCare Health Plans helps to link the entire Mercy Health System together by offering a complete continuum of health care services readily available to its membership. We also offer contracted providers for additional specialties and for those services needed in outlying areas and specialties. This means that our members can receive care from the 18th most integrated healthcare system in the nation and at over 170 provider locations throughout southern Wisconsin and northern Illinois.
 Awarded the 2007 Malcolm Baldrige National Quality Award; the nation's highest presidential honor for quality and organizational excellence, Mercy Health System is a vertically integrated health system with 63 facilities; serving 24 communities, throughout southern Wisconsin and northern Illinois. 97% of Mercy Health System physicians are board certified and 100% are board eligible. This is a remarkable average-much higher than the national average and higher than other area health care providers. Board certification is widely recognized by physicians, health care institutions, insurers and patients as an essential tool to judge that a physician has the knowledge, experience and skills to provide quality health. Please visit the Mercy Health System website at www.mercyhealthsystem.org.
If you have any questions about your health plan benefits, or you would like to speak to a customer service representative, please contact the MercyCare Health Plans Customer Service Department at:
(800) 895-2421
Monday through Friday from 8:30 a.m. to 4:30 p.m.
Frequently Asked Questions
 Do I have to select a Primary Care Provider (PCP)?
 Yes, members are requested to select a PCP to coordinate their care. If a PCP is not chosen, your member ID card will state "unassigned".
Can every member of my family have a different doctor as their PCP?
Yes, each member may choose a different PCP.
How do I change my PCP?
You may change your PCP at any time by calling Customer Service at 1-800-895-2421. The change will be effective immediately.
How do I get a listing of the providers in my network so I can choose a PCP?
You may access your providers online under the provider finder on our home page or contact Customer Service at 1-800-895-2421 to have a Provider Directory mailed to your home. Please be advised that the online directory is our most up-to-date directory for current providers. Please note: The online listing will not show providers that are no longer practicing under MercyCare but may still be available to you for the remainder of the calendar year due to being listed in our published provider directory at the beginning of your plan year.
Do I need a referral to see a specialist that is participating in MercyCare's network and listed in the provider directory?
Some participating MercyCare specialists will require that you have a referral from your PCP but you do not need to get the referral approved by MercyCare.
Can I see a PCP that is not listed in my provider directory if I obtain a referral?
No, you must select a PCP that participates in MercyCare's network.
What if I want to seek services from a provider that does not participate in MercyCare's network of providers and is not listed in the provider directory?
You would need to obtain a referral from a MercyCare doctor and the referral would need to be prior authorized by MercyCare before your appointment or it will not be covered.
How do I go about getting a referral?
You must request one from your MercyCare doctor.
How and when will I know if a referral is approved or not?
You will receive a letter with MercyCare's decision or you may contact customer service at 1-800-895-2421 for referral status.
I do not agree with MercyCare Health Plans decision to deny my referral request to an out-of-plan provider. What are my options?
You should first contact your physician or practitioner who submitted the referral to MCHP and discuss covered alternatives. If your physician or practitioner disagrees with our decision, he or she should contact our Medical Director. In any event, you have the right to file a grievance by contacting customer service, who will in turn advise you how to proceed with the grievance process. The grievance process is also explained at the bottom of your denial letter and in the 'It's Your Choice' book.
Can my member number be changed?
Yes, you may contact Customer Service at 1-800-895-2421 and request that this number be changed. You will receive a new member ID card after the change has been made.
How do I get a new member ID card?
You may contact Customer Service at 1-800-895-2421 to request a new member card.
I have questions about my dental benefits, how do I get these answered?
You may contact Delta Dental at 1-800-236-3713 or click on the Delta Dental link on this website. However, if you are under the local plan these dental benefits do not apply to you.
I have questions about my pharmacy benefits, how do I get these answered?
You will need to contact your pharmacy benefit manager, Navitus Customer Care, at 1-866-333-2757.
I have a child who is attending college outside your service territory, how do they obtain benefits?
They will have access to Emergency or Urgent Care. Non-urgent follow-up care out of the Service Area must be Prior Authorized by MercyCare or it will not be covered. They may also have access to a limited amount (5 outpatient visits) of mental health benefits if Prior Authorized by MercyCare. All other services are not covered by MercyCare.
Do I have an ER co-pay?
Yes, please see your 'It's Your Choice' book for details.
How do I add my child to my health insurance plan?
If you have a newly eligible dependent, you must fill out the appropriate form, which you may obtain from your Human Resources (HR) department. Return the completed form to your HR department.
Do I have a fertility benefit?
Your plan does not cover fertility benefits.
What are my mental health benefits?
Your mental health benefits are unlimited for outpatient and transitional if seen at a participating MercyCare provider. Your inpatient mental health is limited to 30 days per calendar year if seen at a participating MercyCare provider. There are no benefits available if you get care from a provider that does not participate in MercyCare's network.
Do mental health benefits include marriage counseling?
No, marriage counseling is not a covered benefit.
What are my benefits for chemical dependency/AODA?
Your outpatient benefits are limited to an $1800 maximum per calendar year, transitional treatment is limited to a $2700 maximum per calendar year and your inpatient benefits are limited to 30 days per calendar year or a maximum of $6300 per calendar year. These benefits apply if you are seen by a participating MercyCare provider.
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