Prior Authorization Code Changes

Attention providers! Mercy Care has removed hundreds of codes requiring prior authorization from our grids. We did this to reduce some of the administration involved in being part of our provider network.

Prior Authorization Code Changes – FAQ

Mercy Care Prior Authorization Codes

Mercy Care RBHA Prior Authorization Codes

Mercy Care Advantage Prior Authorization Codes

GMH/SU & Non-title Services Prior Authorization Codes

Learn more about our prior authorization process

Mercy Care requires prior authorization for select acute outpatient services and planned hospital admissions. Prior authorization is not required for emergency services. To request a prior authorization, be sure to:

  • Always verify member eligibility prior to providing services.
  • Complete the appropriate authorization form (medical or pharmacy).
  • Attach supporting documentation when submitting. This could include:
    • Recent progress notes documenting the need for the service
    • Lab results
    • Imaging results (x-rays, etc.)
    • Procedure/Surgery reports
    • Notes showing previous treatment tried and failed
    • Specialty notes 

To request an authorization, find out what services require authorization or check on the status of an authorization, please visit our provider secure web portal. For more information about prior authorization, please review Mercy Care's Provider Manuals located under the Provider Information tab on our website.  

You can fax your authorization request to 1-800-217-9345.

Important to Note:  When checking whether a service requires an authorization under Mercy Care’s Participating Provider Prior Authorization Requirement Search Tool, please keep in mind that a listed service does not guarantee that the service is covered under the plan’s benefits.  Always check plan benefits first to determine whether the service is covered or not.  

Certain acute outpatient services and planned hospital admissions require prior authorization before the service can be covered for the member.

Effective April 1, 2012, we implemented the Prior Authorization Requirement Search Tool (or ProPAT), now available through MercyOneSource. The tool allows providers to easily review prior authorization requirements at a code-service group level and to receive immediate Yes/No answers regarding authorization requirements.

For assistance in registering for or accessing this site, please contact your Provider Relations representative at 1-800-624-3879 or 602-263-3000. Or click here to learn more about MercyOneSource.

The chart below illustrates which acute and home- and community-based services provided to ALTCS members require PCP orders and/or authorization by the member’s case manager.

Long-term care services that require prior authorization

SERVICE

Acute hospital admission (Non-Medicare admission)

Adult Day Health Services

Assisted Living Facility

Attendant Care

Behavioral Health Services

DME/Medical Supplies

Emergency Alert

Habilitation

Home-Delivered Meals

Home Health Agency Services

Home Modifications

Homemaker Services

Hospice Services (HCBS and Institutional) [Non Medicare]

ICF/MR

Medical Care Acute Services

Nursing Facility Services

Personal Care

Respite Care (in-home)

Respite Care (Institutional)

Therapies

Transportation

PCP ORDERS

X

X

X

X

X

X

X

N/A

X

X

X

X

CASE MANAGEMENT AUTHORIZATION

X

X

X

X

X

X

X

X

X

X

X

X

X

N/A

X

X

X

X

X

X

X

When you request prior authorization for a Mercy Care member, we’ll review it and get back to you according to the following timeframes:

  • Routine – 14 calendar days upon receipt of request.
  • Urgent – 72 hours upon receipt of request. An urgent request is appropriate for a non-life-threatening condition, which if not treated promptly, will result in a worsened or more complicated patient condition. We encourage you to call the Prior Authorization department at 602-263-3000 for all urgent requests.