Referral and PreCertification  INFORMATION

1. 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 (non-Tier 1), 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 Tier 1 level. The Mercy PHO is not authorized to do retroactive referrals. 
    
2. How do I obtain a referral?
   A Tier 1 (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 three (3) business days for a referral to be processed.  Retroactive referral requests will not be accepted by the PHO office.  A letter from your physician directly to another physician is not considered a referral. 
    
3. Does this referral take the place of any precertification requirements? 
   No. It is essential that services requiring precertification according to Wellmark's precertification guidelines be followed as Mercy is utilizing these guidelines effective 01/01/12.  You may contact precertification at 1-800-558-4409.
    
4. What if I disagree with Wellmark's precertification decision?
   You may appeal a precertification decision by writing a letter addressing your concerns to Wellmark Blue Cross and Blue Shield of Iowa Special Inquiries, PO Box 8121, Station 5W189, Des Moines, IA  50306-9232.  If further appeal of Wellmark's decision is desired, appeal to Mercy Human Resources.
    
5. 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.
    
6. Does the precertification or approved referral by the PHO guarantee payment of claims?
   No.  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 (Tier 2 or higher) benefit levels. Precertification 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).
    
7. How do I know if a procedure needs precertification?
   Wellmark, Mercy Hospital's third-party administrator, reviews all procedures to ensure that they are medically necessary. Mercy Hospitals Health Plan policy does not cover cosmetic surgery.* 

8. What if I need emergency care?
   Emergency hospitalizations must be reported within 48 hours to Wellmark at the phone number listed on your insurance card (maternity cases require notification to Wellmark in advance AND within 48 hours of admission for delivery) or there could be a reduction of benefits.