Medical prior authorization (PA) 

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

Use the ProPat tool to find out if you need PA

You can find out if services need PA by using our ProPat online PA search tool: 

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: 

Verify member eligibility before providing services. You can do this 3 ways:
- Register for your Provider Portal if you haven’t already. Then, sign in to the portal with your credentials.
- Use our interactive voice recognition (IVR) system (PDF), available anytime.
- Contact us for help.
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
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.

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Programs and services

Resources

Medical prior authorization (PA)

Use the ProPat tool to find out if you need PA

Tips for PA

Tips for PA

How to request PA

By phone

By fax

Time frames for PA

Mercy Care Long Term Care PA grid

Questions?