MHP provides a reconsideration (peer-to-peer) and an appeal process for members and providers in the event of an Adverse Determination. An adverse determination is a decision by MHP or its designee, which an admission, availability of care, continued stay or other healthcare service has been reviewed and, based upon the information provided, does not meet MHP’s requirements for coverage. These requirements include medical necessity, appropriateness, healthcare setting, and level of care or effectiveness of care. As a result, the coverage for the requested service is subsequently denied or reduced.
MHP adheres to the following timeframes when making a determination:
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Pre-service requests for urgent conditions |
The medical director will issue a decision within one calendar day of the peer-to-peer opportunity (and receiving complete clinical information to adequately demonstrate the necessity of the treatment/service.) |
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Pre-service requests for non-urgent conditions |
The medical director will issue a decision within three calendar days (72 hours) of the peer-to-peer opportunity (and receiving complete clinical information to adequately demonstrate the necessity of the treatment/service.) |
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Concurrent requests |
The medical director will issue a decision within 24 hours of the peer-to-peer opportunity (and receiving complete clinical information to adequately demonstrate the necessity of the treatment/service.) |
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Pharmacy requests |
See the Pharmacy Section |
Adverse determinations made in the course of the review process are communicated verbally to the provider within one day from when the determination was made. This communication is confirmed within three business days by written notice of the determination and any coinciding recommendations. This letter is mailed to the member or responsible party, the physician, and facility (if applicable). The reasons for the adverse determination, available alternatives and the appeal rights and procedures are included in the notices of denial, along with a contact person’s name and phone number.
If the reconsideration process does not resolve the difference of opinion, the Adverse Determination may be appealed by the provider (on behalf of the member). The member may also utilize the Grievance/Appeals Processes identified in Chapter 8.
Any member or provider may appeal directly to the appeals coordinator at:
Mercy Health Plans
ATTN: Corporate Appeals
14528 South Outer Forty Road, Suite 300
Chesterfield, MO 63017-5743