Referrals/Prior Authorization

Referrals:

Your Primary Care Physician (PCP) may refer you to other providers to get special services. A referral is when your PCP sends you to a specialist for a specific problem. A referral can also be to a lab or hospital, etc. Mercy Care Plan may need to review and approve certain referrals and special services first before you can go get the services. Your PCP will know when to get Mercy Care Plan’s approval. If your referral needs to be approved by Mercy Care Plan, your PCP will let you know what’s happening. You may also request a second opinion from another Mercy Care Plan doctor.

Prior Authorizations:

An authorization is an approval from Mercy Care Plan for you to get the special services your PCP has referred you to. Mercy Care Plan may take up to 14 days to approve a routine authorization request and three (3) business days to approve an urgent request. If Mercy Care Plan needs additional information to authorize the request, a 14 day extension may be requested. If Mercy Care Plan does not receive the information they requested from your doctor, Mercy Care Plan may deny the request. You will receive a notice of action letter that explains your rights. If your doctor sends in an urgent authorization request and it does not meet the criteria for an urgent request, MCP will send you a letter and let you know that it will be processed as a regular request. You can file a grievance if you disagree with an extension of time. Please go to the section on Grievances for more information.
If you have questions about whether your service has been authorized, call your PCP. You do not need approval from Mercy Care Plan to get emergency services.

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Member Services
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Toll-free: 1-866-602-1982

If you or a family member has a medical emergency, dial 911.

Information may not be current
Pending CMS Approval
H5580_11_298