Provider Information

To support inpatient concurrent review decisions, Mercy Care uses nationally-recognized and/or community-developed, evidence-based criteria, which are applied based on the needs of individual members and characteristics of the local delivery system.

Service authorization staff that make medical necessity determinations are trained on the criteria and the criteria are accepted and reviewed according to Mercy Care policies and procedures.

Criteria sets are reviewed annually for appropriateness to the Mercy Care population needs and updated as applicable when nationally or community-based clinical practice guidelines are updated.  The annual review process involves appropriate practitioners in developing, adopting, or reviewing criteria. 

The criteria are consistently applied, considering individual needs of the members and allow for consultations with requesting practitioners/providers when appropriate. For inpatient medical care reviews, Mercy Care uses the following medical review criteria in the order listed:

  • Criteria required by applicable state or federal regulatory agency
  • Applicable MCG as the primary decision support for most clinical diagnoses and conditions
  • Aetna Clinical Policy Bulletins (CPB’s), 
  • Aetna Clinical Policy Council Review (ad hoc)

For inpatient behavioral health care reviews, MCP uses, in the order listed:

  • Criteria required by applicable federal and state regulatory agency
  • MCG, ASAM PPC-2R, CASII, LOCUS
  • Aetna Clinical Policy Bulletins (CPBs)
  • Aetna Clinical Policy Council Review (ad hoc)