There are occasions when MHP requires additional information regarding the medical necessity of a specific service or procedure. MHP asks that our Prior Authorization Department receive this information in a letter or in copies of the member’s medical records.
Examples of such situations include, but are not limited to:
Procedures that could be potentially considered cosmetic;
Treatment of vein varicosities;
Blepharoplasty; and
Experimental/investigational treatment.
Please note: Proof of medical necessity regarding dermatological and potentially cosmetic procedures may require photographs in addition to the written request.
Member's MHP Identification Number;
Member's date of birth;
Detailed explanation of the requested service or item (e.g. drug, out of network, DME, etc.);
Reason for the request;
Place of requested service (if applicable);
Date of the requested service (if applicable);
Summary of the member’s condition;
Any conservative treatments tried;
Labs, other diagnostic tests, and results of same;
Plan of treatment, if possible and expected outcome;
All pertinent ICD-9 codes, HCPCS codes, CPT codes ;
Name and phone number of a contact in the provider’s office; and
The signature of the participating provider on the LOMN.
If the request is for out-of-network services, please include:
The reason the member needs to go out of network;
Which in-network providers have been consulted; and
Medical records from the requesting physician and the consulting physician(s).
Please mail all benefit determinations and responses to requests for medical necessity documentation to:
Mercy Health Plans
Attn: Benefit Determinations
14528 South Outer Forty Road, Suite 300
Chesterfield, MO 63017-5743
If preferred, fax documentation to 314-214-8201 or 800-466-9854.