Referrals & Prior Authorization

Getting specialty services

There are times when a health problem can’t be treated by your doctor alone and specialty care may be needed. If you need care from a specialty provider, your PCP will need to request a referral for you. Some covered medical services will need prior authorization before you can receive the service.

Referrals

A referral is when your primary care provider (PCP) sends you to a specialist provider for a specific problem. This might include heart problems, skin disorders or serious allergies. A referral can also be to a lab or hospital, etc. You may also request a second opinion from another Mercy Care doctor.

Prior authorizations

A prior authorization is an approval from Mercy Care for you to get the special services your PCP or specialist provider wants you to receive. We may take up to 14 days to approve a routine authorization request and three (3) business days to approve an urgent request.

If we need additional information to authorize the request, a 14-day extension may be requested. If we do not receive the information requested from your doctor, we may deny the request. You will receive a notice of action letter that explains your rights. 

If your doctor sends in an urgent authorization request and it does not meet the criteria for an urgent request, we will send you a letter and let you know that it will be processed as a regular request. You can file a grievance if you disagree. Please go to Grievances for more information.

Click on the links below to see if a service requires pre-approval. You do not need approval from Mercy Care to get emergency services.

Mercy Care providers are expected to follow certain guidelines when giving our members care. If you need help understanding any of these guidelines, please call Member Services and ask to speak to a nurse who can help you.

Important update for Mercy Care Advantage members requiring specialty services

Certain acute outpatient services and planned hospital admissions require prior authorization before the service can be covered. Please refer to the Evidence of Coverage for more explanation about which services and circumstances require prior authorization.