February 13, 2020
Prior Authorization requirements for Inpatient Behavioral Health Providers Update

Applicable to: Mercy Care Complete Care, Mercy Care RBHA, Mercy Care Long Term Care and Division of Developmental Disabilities 
This previously sent provider notice is being updated. It was originally sent on 9/27/2019. 

Mercy Care will no longer require prior authorization or concurrent reviews when we are secondary payer to commercial insurers or a non-Mercy Care Advantage plan or Medicare FFS. Please check eligibility and benefits prior to requesting authorization from Mercy Care. We ask that you contact the primary insurer for authorization and continued stay reviews. Below please find some Frequently Asked Questions which may assist you with this. 
Frequently Asked Questions

When does Mercy Care become the primary payer?
  • If a patient is no longer enrolled in a commercial plan and loses their benefits, or does not have IPBH benefits.
  • If a Medicare FFS patient has exhausted their lifetime limit on their IPBH benefit. In order to complete an authorization, the facility is required to send the eligibility/benefit limit report from CMS as proof of lifetime limit exhausted.

What if the primary payer denies the service as not medically necessary?
  • If the commercial insurer denies a continued stay because their member does not meet medical necessity criteria, the patient must exercise their appeal rights with that insurer. Mercy Care will not assume primary payment. 

What if you need assistance or have questions regarding coordination of benefits?
  • Please contact the Mercy Care Utilization Management Clinician assigned to your facility.

What if you need assistance with discharge planning for a patient with Medicare or commercial insurance?
  • Please contact the Mercy Care Discharge Coordinator assigned to your facility.

What if there is a delay in discharge due to availability of services at a lower level of care that would be covered by Mercy Care?
  • Please contact the Mercy Care Utilization Management Clinician or Discharge Coordinator assigned to your facility for assistance. 

Our Mercy Care Utilization Management team is always available to assist with discharge planning and coordinating transitions in care. We understand that there may be exceptions and special circumstances that require our assistance, and we encourage you to reach out to our clinicians for guidance with these matters.

As always, don't hesitate to contact your Mercy Care Network Management Representative with any questions or comments. You can find this notice and all other provider notices on our Mercy Care website.

We appreciate your continued assistance, support and cooperation!