W1 - MercyCare HMO Plans

 

MercyCare HMO Benefits

The foundation of MercyCare Health Plan is to have each MercyCare member develop a caring, professional relationship with a Primary Care Physician (PCP) whom will coordinate and manage your medical care. All HMO plans require members to use the Provider network established except in the case of emergency care.

Choosing a Primary Care Physician (PCP)

A PCP is a doctor who practices in one or more of these fields: Family Medicine, Internal Medicine and Pediatrics. Each family member must select a doctor in one of these fields. Women may select an OB/GYN for routine gynecologic and obstetrical care, yet must still select a PCP for all other services. Please refer to our Provider Directory for a complete list of network PCPs.

Specialist Providers

MercyCare Health Plan has a comprehensive list of specialists to meet the health care needs of our members. You do not need a referral from your PCP to see any of our network specialists, but we encourage you to coordinate specialist care with your PCP.

Emergency Care

Members who have a medical emergency within the MercyCare service area should, if possible, seek immediate attention at the nearest network provider. Members who have a medical emergency outside the MercyCare network should seek care at the nearest emergency facility. MercyCare should be notified within 48 hours, or as soon as possible.

No Claim Forms

When members use MercyCare providers, claim forms are not required and tedious paperwork is eliminated. Please make sure you show your identification card to the MercyCare provider so that you are assured a paperless visit.

Provider Network
A group of providers contracted with the plan to provide services for members within a specific geographic location as specified in MercyCare's Provider Directory. The primary care physician you select directly determines the provider network in which you will be associated. 

Co-payments (Co-pay)
The fixed amount or percentage of eligible expenses you must pay to the provider for benefits received.

General Exclusions:

  • Services that are not medically necessary

  • Cosmetic or elective orthodontic care, periodontic care or general dental care

  • Experimental procedures 

  • Custodial care and convalescent care 

  • Hospice care provided outside the member's home 

  • Routine or preventative physicals when they are primarily at the request of, for the protection of, or to meet the requirements or, a party other than the member 

  • Eyeglasses and contact lenses 

  • Expenses incurred prior to membership, or services received after the coverage or eligibility terminates 

  • Acupuncture, holistic or homeopathic medicine 

  • Reversal of voluntary sterilization procedures and related procedures 

  • Any surgical treatment or hospitalization for treatment of morbid obesity 

  • Weight loss programs 

  • Medical supplies and equipment for comfort, personal hygiene and convenience such as but not limited to: air conditioners, humidifiers, physical fitness equipment and self help devises not medical in nature 

  • Benefits provided for or are payable by Workers' Compensation 

  • Skin tag removal 

Main Telephone:   Out-of-Area:            (800) 752-3431 

                              Local:                      (608) 752-3431

                              Customer Service:   (800) 895-2421



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View the HMO Certificate of Coverage by clicking here or the icon above.

 

If you would like a paper copy of your schedule or summary of benefits,  please contact our Customer Service department at:

(800) 895-2421


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