Prior Authorization Guidelines

Mercy Care Plan/Mercy Care Advantage's Utilization Management program involves prospective, retrospective and concurrent utilization review activities. Prior authorization, or prospective review, is the first step in a utilization management program and means the plan will decide in advance whether to cover a specific service. The following guidelines describe Mercy Care Plan/Mercy Care Advantage's criteria for prior authorization of certain services.
Prior Authorization Requirements
(Last Reviewed 04/13/2004)
Guidelines Last Reviewed Date
Adult Pulmonary Arterial Hypertension (PAH) 06/16/2005
Breast Reconstruction 05/18/2006
Circumcision Medically Necessary 05/18/2006
Criteria for Authorization of Synagis® 06/29/2005
Fetal Fibronectin Enzyme Immunoassay 05/18/2006
Gastric Bypass 04/01/2005
General OB Care 06/16/2005
Genetic Testing and Counseling 06/16/2005
Home Uterine Activity Monitoring 05/18/2006
NICU/Nursery/Step-Down Utilization 06/16/2005
Pre-Conceptual Genetic Counseling 06/16/2005
Recombinant Human Growth Hormone in Children 10/14/2004
Supplemental Nutritional Feedings 10/14/2004
Vision Screening 06/16/2005
Xolair 10/12/2004

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August 20, 2008