Prior Authorization

Codes that require Prior Authorization

A list of codes that require prior authorization are available on our Online Prior Authorization Search Tool.

Learn more about our Prior Authorization process

Mercy Care RBHA 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 check on the status of an authorization, you can visit our provider secure web portal.

You can fax your authorization request to 1-844-424-3976 or 1-860-902-8747.

For behavioral health inpatient requests, fax to 1-855-825-3165.

Important to Note:  When checking whether a service requires an authorization under Mercy Care RBHA's Online Prior Authorization Tool, you should keep in mind that a listed service doesn't 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.

A list of codes that require prior authorization are available on our Online Prior Authorization Search Tool .

For assistance in registering for or accessing this site, please contact your Provider Relations representative at 1-800-564-5465 (toll-free), hearing impaired (TDD/TTY) 711.

When you request prior authorization for a Mercy Care RBHA 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 1-800-564-5465 (toll-free), hearing impaired (TDD/TTY) 711, for all urgent requests.