How do I obtain a referral?

If your participating physician feels you need services not available within your participating network of providers, he/she may submit a referral request to MercyCare Health Plans.

Upon receipt of the referral request it will be reviewed by our Quality Health Management Department.  When the review is complete, you, your participating provider and your requested referral provider will receive a letter advising of the outcome of the review.  If the referral is approved, the letter will state; in detail, the dates and services that are approved.  If the referral is denied or redirected back to a plan provider, you will receive a letter stating why the referral was denied or redirected.  You will also receive information on your rights to grieve the outcome of the review.

What is an EOB?  Why does it tell me I owe my provider a co-pay when I paid it at the time of my appointment?

 A MercyCare EOB is an Explanation Of Benefits.  An EOB will show how your claim was processed in accordance to the benefit plan chosen by your employer.  The EOB is for your reference and to assure the amount billed by the provider matches the amount we say you owe.  You may also use the EOB for your flexible spending account reimbursement or for tax purposes.

An EOB will state 'YOU OWE THE PROVIDER $xx.xx' if there is a portion of the claim that is your liability.  Because MercyCare does not know if you have already made a payment at the time of your service, it merely explains that according to your benefit plan you may have a balance due.  This balance could be due to a co-pay, co-insurance or the deductible depending on the services received on that date of service.  MercyCare does not have access to your providers' computer; therefore, we do not know when a member liability has been paid.

 I will be traveling out of the country and require vaccinations - will they be covered?

Vaccinations required to travel outside of the United States may be considered an eligible benefit if it is related to personal travel.  MercyCare does not cover those vaccinations required for business travel.  Due to this, Prior Authorizations will be required to determine if services will be covered.  The Prior Authorization process will also allow us to advise you on what vaccinations are needed; or not needed, based on the country you are traveling to.

What is an IER?  When and How can I request one?

An Independent External Review (IER) is an additional way to resolve some disputes involving medical decisions. This process provides you (or your authorized representative) with an opportunity to have medical professionals who have no connection to MercyCare review your concern. All of the Independent Review Organizations (IRO's) are certified by the Wisconsin Office of the Commissioner of Insurance(OCI).

You may request an IER only after completing MercyCare's internal Grievance process. After you receive MercyCare's final decision letter regarding your grievance, you (or your authorized representative) can choose an IRO from the list provided with this final decision letter. You would then send a written request for an independent review to MercyCare along with the following:

• Your name, address and telephone number. 
• A check in the amount of $ 25.00 payable to the IRO of your choice.
• An explanation of why you believe that the treatment should be covered. 
• Any additional information or documentation that supports your position. 
• If someone else is filing on your behalf, a statement signed by you authorizing that person to be your representative 

MercyCare will then submit all relevant medical records, and other documentation used in making its decision to the IRO within five business days. The IRO then has five business days to review the information that it has received and to request any additional information it may need from MercyCare or from you.  After the IRO has received all the information that it needs the IRO then has thirty (30) business days to make its decision.

The final determination by the IRO is then binding by both MercyCare and you. If the IRO decides in your favor, MercyCare will refund you the $ 25.00.

Need further assistance with any of these questions; or a different question?  Please call us at (800) 895-2421 and one of our friendly, helpful Customer Service representatives will be happy to assist you.