St. Louis Provider Manual
    Table of Contents
    Contact Information
    About Mercy Health Plans
    1. Member Information
       1.1. Mercy Health Plans Product Overview
       1.2. Members Rights and Responsibilities
       1.3. Advance Directives
       1.4. Nurse on Call
    2. Provider Relations
       2.1. Provider Relations
       2.2. Freezing Primary Office Enrollment
       2.3. Provider-Initiated Office Change
       2.4. Medical Records
    3. Medical and Pharmacy Benefit Management
       3.1. Provider Responsibilities
       3.2. Out-of-Network Provider Requests
       3.3. Medical Management Services
       3.4. Requests for Documentation of Medical Necessity and
       3.5. Utilization Management Adverse Determination Process
       3.6. Mental Health and Substance Abuse Services
       3.7. Pharmacy Benefit Services
    4. Quality Improvement
    5. Credentialing
    6. Clinical Adverse Events Investigations
    7. Fraud, Waste and Abuse
    8. Complaint, Grievance & Appeals Processes
       8.1. Provider Complaint, Grievance, and Appeal Process
       8.2. Member Complaint, Grievance, and Appeal Process
    9. Billing Guidelines
       9.1. Claims Submission
       9.2. Maintaining Accurate Provider Information
       9.3. Billing Guidelines for All Services
       9.4. Billing Guidelines for Professional Services
       9.5. Anesthesia Billing Guidelines: All Plans
       9.6. Surgical Billing Guidelines
       9.7. Obstetrical Billing Guidelines
       9.8. Durable Medical Equipment, Prosthetics, Orthotics and
       9.9. General Institutional Billing Guidelines
       9.10. Correct Coding Software
       9.11. Coordination of Benefits (COB)
    10. Physician and Member Satisfaction Surveys
       10.1. Physician Satisfaction Survey
       10.2. Member Satisfaction Surveys
    11. Benefits and Limitations: Commercial Products
       11.1. Eligibility
       11.2. Benefits
       11.3. Limitations and Exclusions
       11.4. Point of Service (POS) Information
    12. Mercy MedicareADVANTAGE Benefits and Limitations
       12.1. Mercy MedicareADVANTAGE Eligibility Criteria
       12.2. Benefits
       12.3. Transition of Care Form
       12.4. Medicare Reporting Form
       12.5. Medicare Risk Adjustment Program
    13. Standards for Medical Record Keeping
       13.1. Confidentiality of Medical Records
       13.2. Medical Record Release to the MHP Member
       13.3. Medical Record Release to Mercy Health Plans
       13.4. Medical Record(s) Maintenance
       13.5. Documentation Standards
       13.6. Medical Record Review/Audit