When Is Prior Authorization Required?

Certain acute outpatient services and planned hospital admissions require prior authorization before the service can be covered for the member.

Effective April 1, 2012, Mercy Care Plan implemented the Prior Authorization Requirement Search Tool (or ProPAT), now available through the MercyOneSource site. 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 (800) 624-3879 or (602) 263-3000. Or click here to learn more about MercyOneSource.

In addition, the chart below illustrates which acute and home- and community-based services provided to ALTCS members require PCP orders and/or authorization by the member’s case manager.

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
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 (HCBS and Institutional) [Non Medicare] X X
ICF/MR N/A N/A
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

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