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Medical prior authorization (PA) 

PA is required for some acute outpatient care and planned hospital admissions. We don’t require PA for emergency care. 

 

Tips for PA 

Tips for PA 

Always check plan benefits first to find out if the service is covered. A listed service or a request for PA doesn’t guarantee coverage or payment. You can make requesting PA easier with these tips: 

  1. Verify member eligibility before providing services. You can do this 3 ways:
  2. When you submit the correct form, attach supporting documents, like:
    • Recent progress notes that explain the need for the service

    • Lab or imaging results

    • Procedure or surgery reports

    • Notes showing previous treatment tried and failed 

  3. Once you’ve requested PA by phone or fax, you can check the status of your PAs on your Provider Portal
 

How to request PA 

You can request PA: 

By phone

Just call us to start the PA process.

By fax 

Visit our forms page to get the PA request form you need. Then, fax it to the plan, along with supporting materials:

  • Mercy Care ACC-RBHA with SMI behavioral health inpatient requests: 1-855-825-3165

  • Mercy Care ACC-RBHA with SMI behavioral health outpatient requests: 1-800-217-9345

  • Mercy Care Medicaid plans and Mercy Care Advantage outpatient requests: 1-800-217-9345

Time frames for PA

When you request PA, we’ll review it and get back to you based on these time frames: 

Routine: 14 calendar days upon receipt of request 

Urgent: 72 hours upon receipt of request 

Extension: An additional 14 days if we need more clinical documentation

  • We’ll notify both the provider and member of this extension and detail the request for more documentation.

  • If we don’t receive the supporting documentation within the requested time frame, we may deny the request for PA on the date that the time frame expires.

Urgent requests are for non-life-threatening conditions. If not treated promptly, they can result in a worsened or more complicated condition. Call us for all urgent requests. 

 

Mercy Care Long Term Care PA grid

Mercy Care Long Term Care has a specific PA grid for support services.

 

Service

PCP orders

Case management authorization

Acute hospital admission 
(Non-Medicare admission)

X

X

Adult day health services

X

Assisted living facility

X

Attendant care

X

Behavioral health services

X

X

Durable medical equipment (DME)/medical supplies 

X

X

Emergency Alert

X

X

Habilitation

X

Home-delivered meals

X

Home health agency services

X

X

Home modifications

X

X

Homemaker services

X

Hospice services: Home and community-based services (HCBS) and institutional [Non Medicare]

X

X

Intermediate care facilities for individuals with mental retardation (ICF/MR)

NA

NA

Medical care acute services

X

X

Nursing facility services

X

X

Personal care

X

Respite care (in-home)

X

Respite care (Institutional)

X

X

Therapies

X

X

Transportation

X

Service

Acute hospital admission 
(Non-Medicare admission)

PCP orders

X

Case management authorization

X

Service

Adult day health services

PCP orders

Case management authorization

X

Service

Assisted living facility

PCP orders

Case management authorization

X

Service

Attendant care

PCP orders

Case management authorization

X

Service

Behavioral health services

PCP orders

X

Case management authorization

X

Service

Durable medical equipment (DME)/medical supplies 

PCP orders

X

Case management authorization

X

Service

Emergency Alert

PCP orders

X

Case management authorization

X

Service

Habilitation

PCP orders

Case management authorization

X

Service

Home-delivered meals

PCP orders

Case management authorization

X

Service

Home health agency services

PCP orders

X

Case management authorization

X

Service

Home modifications

PCP orders

X

Case management authorization

X

Service

Homemaker services

PCP orders

Case management authorization

X

Service

Hospice services: Home and community-based services (HCBS) and institutional [Non Medicare]

PCP orders

X

Case management authorization

X

Service

Intermediate care facilities for individuals with mental retardation (ICF/MR)

PCP orders

NA

Case management authorization

NA

Service

Medical care acute services

PCP orders

X

Case management authorization

X

Service

Nursing facility services

PCP orders

X

Case management authorization

X

Service

Personal care

PCP orders

Case management authorization

X

Service

Respite care (in-home)

PCP orders

Case management authorization

X

Service

Respite care (Institutional)

PCP orders

X

Case management authorization

X

Service

Therapies

PCP orders

X

Case management authorization

X

Service

Transportation

PCP orders

Case management authorization

X

Questions?

Check out your provider manual. Or contact us