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.

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 two (2) 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.

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.

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.