Prior Authorization is a process MHP employs to ensure that members receive medically necessary, cost-effective, covered benefits in the most appropriate setting and that members are identified early for home care and other case management needs. At the time of prior authorization, the service is either certified based on the medical information provided or not certified, as there may be alternatives available. Please note that MHP assures that a member’s treatment regimen will not be interrupted or delayed, nor will immediately required medically necessary supplies and/or pharmaceuticals be withheld during the Prior Authorization process.
For those services that require Prior Authorization, it is important to know that MHP (and our delegates) conducts these activities with the member’s medical needs as a priority. Prior Authorization is not an attempt to deny medical care. Rather, it is a verification process whereby the member is ensured the most appropriate care in the most efficient setting. The process also assists members and providers alike in understanding what services are covered under the member’s benefit package and what, if any, financial liability the member may bear by choosing to receive non-covered benefits.
Please remember: It is the responsibility of the treating physician to notify MHP’s Prior Authorization Department at 314-214-8282 or 800-647-2240 before rendering any elective service.
Hospitals are required to notify MHP of any direct admissions from the Emergency Room within 48 hours of that event for all members.
Emergency room screenings and/or treatments do not require notification to MHP.
Access mercyhealthplans.com to view CPT codes that require prior authorization. For those codes not available online, please call for prior authorization, 314-214-8282 or 800-647-2240.
MHP uses nationally recognized clinical criteria sets including, but not limited to InterQual, for the screening and evaluation of covered services subject to the benefit determination, prior authorization, concurrent review, and other utilization/benefit management processes. Other clinical resources include, but are not limited to Hayes, Inc. (a technology evaluation resource), CMS Notices of Coverage, and locally developed medical, benefit, and pharmacy policies. All guidelines and criteria sets are based on information published in peer-reviewed literature. The chief medical officer, associate medical director, and/or physician advisors make all Adverse Determinations regarding medical necessity based on this information and the individual's unique healthcare needs.
A checklist for your convenience to prepare before calling for Prior Authorization follows on the next page. It is not to be submitted.
For your information only &endash; Do not submit
_____Member’s Name
_____MHP Identification Number
_____Admitting Physician’s Name
_____Contact Name in Provider’s Office and Phone Number
_____DX (ICD-9) and Procedure Codes
_____Procedures Requested (including CPT-4 codes)
_____Clinical History
_____Inpatient/Outpatient Observation
_____Additional Comments
Call for Prior Authorization
MERCY HEALTH PLANS
MEDICAL MANAGEMENT
314-214-8282 or 800-647-2240
A pre-service consultation with RadConsult® is required for all outpatient, non-emergent MRAs, MRIs, CTs, CTAs, PET scans and selected nuclear medicine cardiac procedures.
The consultation process involves:
Contacting RadConsult® by the ordering physician’s office staff member at the following: phone, 866-389-3875; fax, 877-883-5684; or www.healthhelp.com/mercyhealthplans. For maximum efficiency, please have the member’s chart available when calling.
The RadConsult® representative collects relevant clinical information for the recommended procedure (including the member’s diagnosis, the test being recommended, the reason for the test, duration of symptoms, prior imaging studies, laboratory studies, medications, and prior treatments).
The RadConsult® team evaluates this information in conjunction with current evidence-based guidelines.
When necessary, the RadConsult® physician advisor will initiate a discussion with the ordering physician regarding test appropriateness and member safety.
RadConsult® provides the ordering physicians or their office staff with a tracking number for the procedure at the end of the interaction. As this is an educational process, a tracking number is provided even if the ordering physician and physician advisor fail to agree.
Failure to complete the consultation process results in an administrative denial of associated radiology claims (hospital, radiologist, and/or freestanding facility providers). Members are not responsible for denied charges.
This process is not intended to obstruct or delay member care and as always, MHP continues to recognize that the responsible physician’s judgment remains paramount.
Codes for procedures requiring authorizations are available at mercyhealthplans.com
Authorization Requirements When Mercy Health Plans is Secondary Payor
For purposes of this section, ”authorization requirements” refers to referrals, prior authorizations, and network limitations of the primary carrier.
If it is verified that MHP is the secondary insurance for a member and the member has met the authorization requirements of the primary insurance carrier (as verified by the information received on the primary carrier’s explanation of benefits), MHP’s authorization requirements are waived.
Concurrent Review
Once prior authorization is given for a hospital admission, continued stay review, discharge planning, and case management may be conducted. Continued stay review decisions are made in conjunction with national guidelines and the individual member’s specific needs and is completed by nurses under the guidance of the chief medical officer, associate medical director, or physician advisor.
Initial reviews are usually completed within 24 hours of the member’s admission. Subsequent reviews are completed as needed for each individual patient and the clinical information is evaluated to:
Verify that continued hospitalization is medically necessary and appropriate;
Assist the nurses in discharge planning which includes reviewing the member’s benefits;
Identify resources and gauge the member’s educational needs prior to discharge; and
Identify the potential for case management.
Case Management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs. Case managers work closely to assist physicians with members who have been identified as having chronic, potentially catastrophic diagnoses. Case managers are familiar with the MHP service area, participating providers and facilities, the members’ benefits and available educational and other community services that, when combined, may assist members in avoiding an exacerbation of their illness and/or a hospital stay.
MHP’s multi-disciplinary team includes physicians, registered nurses, social workers, registered dieticians, and health educators. Case managers provide on-going telephone contact with the member, and can assist physicians and members in coordinating required ancillary services. Case managers assess diagnosis, health history, current needs and the treatment plan in order to determine the level of involvement required. Involvement may include:
Education about the disease;
Support member in meeting their personal goals;
Discharge planning;
Care coordination;
Utilization management; and
Provide community services and resources.
If you have an MHP member who might benefit from case management services please call 866-222-6655.
The primary goal of the New Beginnings Program is to improve the health outcomes for our pregnant members through collaboration between each member, their healthcare team, and our case management staff. Members enrolled in the program will receive:
Access to a registered nurse case manager;
Educational mailings tailored to each trimester of pregnancy;
Coordination of care and services, as needed;
Information on prenatal classes and community resources; and
Incentives available upon completion of the program.
To refer your pregnant members to the New Beginnings Program please complete the Pregnancy Risk Screening and Notification form. The form can be found at provider.mercyhealthplans.com. The form can be submitted by email to mhpcmrequest@mercy.net or by fax at 314-214-8210.
Prenatal Class Reimbursement
MHP promotes prenatal education as vital to the successful delivery of healthy babies. All Commercial pregnant members are eligible for a $75 reimbursement for prenatal childbirth classes at the participating facility of their choice. Members may obtain additional information through the Member Services Department at 314-214-8196 or 800-327-0763.
MHP is committed to providing our membership with tools to assist them in making healthy lifestyle choices. Our Health and Wellness Department is a critical part of our Care Coordination team. Our wellness initiatives include:
Health Risk Assessments (HRAs);
Health Coaching (electronic) ;
Health and Wellness newsletters;
Support and guidance for employer wellness programs;
Flu vaccine education and promotion;
Health literacy; and
Promotion of health and wellness benefits.
Our commercial members are eligible for a tobacco cessation benefit. MHP offers both educational and/or pharmacological approaches to smoking cessation.
Members with pharmacy benefits through MHP are eligible for coverage of smoking cessation products such as bupropion extended-release (generic Zyban), Chantix or nicotine replacement products such as Nicotrol inhaler, Nicoderm patches, or Nicorette gum. In order to receive coverage for the over-the-counter nicotine replacement products please provide your patient with a prescription. The member may then have it filled at the pharmacy. Pharmacy co-payments will apply for prescriptions, and there is a six month supply limitation. MHP will not reimburse for smoking cessation products that are not processed through the pharmacy benefit.
Transition of care governs new members under the care of a non-participating physician as well as established members whose specialty provider’s contract terminates (for reasons other than cause). All who qualify must complete a Transition of Care/Release of Medical Information form. A case manager reviews the documentation upon either the member’s enrollment or notification of the provider’s termination and then will assist the member through the transition of care.
Examples of cases requiring transition of care include:
Women who are in or beyond their 14th week of pregnancy and all high-risk pregnancies shall be allowed to continue through their post-partum period with a non-participating OB/GYN;
Members with a life expectancy of less than six months;
Premature infants and/or devastated children (e.g., CP, CF, hemophilia, and endocrine disorders) may continue with a non-par physician up to age six months. A letter of medical necessity is required beyond this time period;
Members undergoing initial chemotherapy will be allowed to continue with a non-par physician through remission or stability;
Asthmatics seeing a non-par pulmonologist may continue for 90 days; and
Diabetics seeing a non-par endocrinologist may continue for 90 days.
Transitioning care necessitates a member assessment by a MHP Case Manager. This assessment includes:
Review of the treatment plan;
Current progress toward treatment plan goals;
Available network options;
Anticipated length of treatment; and
Admitting privileges of physician(s).
The chief medical officer, associate medical director and/ or a physician advisor reviews all cases beyond the standard qualifying period described. In the case of a provider’s termination, the 90-day transition period as specified in the provider’s contract starts the earlier of the date the member receives notice or the date MHP ends its contract with the provider.
Case managers negotiate individual reimbursement agreements, send appropriate documentation, and enter appropriate authorizations. All services remain subject to appropriate benefit limitations and exclusions.