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. 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.

Practice guidelines can be seen by clicking on the following link, http://www.guideline.gov/. These are the standards that Mercy Care providers are expected to follow when giving our members care. If you need help understanding any of these guidelines, please call Mercy Care and ask to speak to a nurse who can help you.

4350 E. Cotton Center Blvd.,
Bldg D, Phoenix,
Arizona 85040
Mercy Care Plan Member Services
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602-263-3000
Toll-free 800-624-3879

Mercy Care Advantage Member Services
24 hours a day, 7 days a week
602-263-3000
Toll-free 800-624-3879
Select the Mercy Care Advantage option

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

Information may not be current
Pending CMS Approval
H5580_11_298