Provider Manual

• Complete Provider Manual (PDF)
  Download the entire manual.

• 2011 Provider Manual Updates (PDF)

• Non-Participating Provider Emergency Services Payment Guidance (PDF)

View/Print sections of the Provider Manual

• Table of Contents (PDF)

• Introduction (PDF)
  About Keystone Mercy, NPI Number, Telephone Numbers and Definitions

• Section I (PDF)
  Covered Benefits

• Section II (PDF)
  Referral and Authorization Requirements

• Section III (PDF)
  Member Eligibility

• Section IV (PDF)
  Provider Services

• Section V (PDF)
  Primary Care Provider (PCP), Specialist Office Standards and Requirements

• Section VI (PDF)
  Claims and Claims Disputes

• Section VII (PDF)
  Practitioner/Provider Dispute/Appeal Procedures, Member Complaints, Grievances and Fair Hearings

• Section VIII (PDF)
  Quality Management, Credentialing and Utilization Management

• Section IX (PDF)
  Special Needs and Case Management

• Section X (PDF)
  Member Rights and Responsibilities

• Section XI (PDF)
  Regulatory Provisions

• Section XII (PDF)
  Medical Assistance Manual and MA Regulations - Chapter 1101

• Appendix (PDF)
  • Supply Request Form (PDF)
  • Hospital Notification of Emergency Admission Form (PDF)
  • Referral Form (PDF)
  • Obstetrical Needs Assessment Form (ONAF) - 2011 (PDF)
  • Obstetrical Needs Assessment Form (ONAF) - 2012 (PDF)
  • DPW MA-112 Newborn Form (PDF)
  • Listing of Reference and Outpatient Laboratories (PDF)
  • Mobile Phlebotomy Service Providers (PDF)
  • EPSDT Physician's Desk Guide (PDF)
  • PA EPSDT Periodicity Schedule and Coding Matrix (PDF)
  • 2012 Immunization Table 0 - 6 years (PDF)
  • 2012 Immunization Table 7 - 18 years (PDF)
  • 2012 Immunization Catch-Up Schedule (PDF)
  • Updated Requirements and Resources for Structured Screening for Developmental Delays and Autism Spectrum Disorder for Medical Assistance Recipients (PDF)
  • Observation Billing Guidelines (PDF)
  • Provider Reference Guide (PDF)
  • Pharmacy Forms
  • Provider Change Form (PDF)
  • Procedures Reimbursed above Capitation Section (PDF)
  • Claims Appeals Spreadsheets Section (PDF)
  • Enrollee Consent Form for Physicians Filing a Grievance on Behalf of a Member (PDF)
  • Domestic Violence - Resources for Patients (PDF)
  • Non-Participating Provider Emergency Services Payment Guidance (PDF)
  • NQF Serious Reportable Events in Health Care (PDF)
  • Preventable Serious Adverse Event Screening Codes (PDF)
  • MA Bulletin 99-10-14 Missed Appointments (PDF)