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Referral,
Pre-notification (certification), and
Pre-authorization Processes
- I am a Mercy Iowa City or Mercy Services employee. Do I require
a referral?
If you are planning to utilize an out-of-network provider,
facility, or hospital, you must follow the referral procedure of the
health plan. All referrals must be done and approval received prior
to services being rendered in order for the benefits to be paid at
the in-network level. The Mercy PHO is not authorized to do
retroactive referrals.
- How do I obtain a referral?
An in-network provider must make the referral. You should make
sure the in-network provider completes the "Out-of-Network Referral Form"
and forwards it to the PHO for physician review. Your provider may
fax the referral to 319-358-2628 to expedite the review process. The PHO physician review will make a decision regarding this request and
notify you and your provider(s) in writing
of its decision. Referrals must be received and authorized by
the PHO office prior to services being rendered.
Please allow two (2) business days for a referral to be
processed. Retroactive referral requests will not be accepted by the PHO
office.
- Does this referral take the place of any pre-notification
(pre-certification) requirements?
No. It is essential that inpatient hospital admissions, hospice,
or home health care services are pre-certified. Call CareAllies at
1-800-533-1314.
- What if I disagree with CareAllies' pre-notification
(pre-certification) decision?
You may appeal an Intracorp decision by writing a letter
addressing your concerns to Mercer Administration, PO Box 4542,
Iowa City, IA 52244-4542. If further appeal of Mercer's
decision is desired, appeal to Mercy Human Resources.
- What if I disagree with a decision of the PHO?
To appeal a decision, please submit a written request of appeal
to the PHO office, c/o Appeal Process, 625 S. Gilbert Street, Suite
2, Iowa City, IA 52240. Include a copy of the decision that you
received as well as an explanation as to why you disagree with the
decision. Your information will be reviewed by the Professional
Services Committee, which is comprised of physicians and Mercy
Hospital administrators. The Committee will issue a written decision
within 30 working days of receipt of the notice of appeal.
- Does the pre-notification (pre-certification) or approved
referral by the PHO guarantee payment of claims?
No. All claims are paid in accordance with the PHN master plan
document. If claims are payable under the plan document, then proper
referrals from the PHO assure payment of claims at in-network versus
out-of-network benefit levels. Pre-notification (pre-certification)
of services (identified in step 4 above), assure no penalties are
applied in processing payment of your claim (details provided in
your summary plan description booklet).
- How do I know if a procedure needs to be preauthorized
(Benefit Predetermination)?
Mercer, Mercy Hospital's benefit administrator,
reviews all procedures to ensure that they are medically necessary.
Mercy Hospitals Health Plan policy does not cover cosmetic surgery.*
Below is a list of procedures that may require additional
information to determine the medical necessity.
Please note
that this is not meant to be an all-inclusive list.
|
Medical Procedure
|
Information Needed to Determine Medical
Necessity |
| *Any procedure which may be
cosmetic in nature |
At minimum medical records. |
| Blepharoplasty - ptosis repair, eye
lid repair |
Medical records, visual fields, and
actual photographs |
| Breast Reduction |
Medical records and actual
photographs |
| Corrective Nasal Surgery and
Turbinates Resection |
Medical records |
| CPAP |
Medical records and physician's
prescription |
| Excision of Varicosities |
Medical records |
| Gastroplasty, Gastric Bypass,
Roux-en-y Gastric Bypass |
Medical records |
| Growth Hormones |
Medical records |
| Light Therapy |
Medical records |
| Physical Therapy |
Referring physician orders and
treatment plan including intended duration and frequency may be
required. |
| Radiofrequency Ablation Therapy |
Medical records |
| Synagis Injections |
Medical records |
| Synvisc Injections |
Medical records |
To ensure the procedure is a covered benefit:
Members are encouraged to have their provider submit the
requested information to Mercer for
pre-authorization, prior to performing the procedure.
To ensure the procedure is paid at the in-network benefit level:
If an in-plan provider or facility does not perform the
procedure, the referring in-plan provider must submit an Out of
Network Referral Authorization Form to the PHO office
prior to the service being performed. PHO approval must be
received by the employee before out-of-network services are rendered
in order for the benefit to be paid at the in-network level.
- What if I need emergency care?
In-network or out-of-network emergency hospitalizations must be
reported within 48 hours to CareAllies at 1-800-533-1314 (maternity
cases require notification to Intracorp in advance AND within 48
hours of admission for delivery). If traveling out of the
network area, covered expenses are subject to your in-network
deductible (inclusive with other plan services subject to the
deductible), and co-insurance as specified in the summary plan
description. In-area emergency care should be sought whenever
possible through an in-network provider.
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