Prior Authorization
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 request an authorization, find out what services require authorization or 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 Participating Provider Prior Authorization Requirement Search 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.
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Services that require prior authorization
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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 request an authorization, find out what services require authorization or 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 Participating Provider Prior Authorization Requirement Search 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.
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Services that require prior authorization
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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 the provider secure web portal . 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 1-800-564-5465 (toll-free), hearing impaired (TDD/TTY) 711.
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Prior Authorization Forms
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Timeframes for processing requests
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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.