www.MercyCareAZ.org
April 20, 2022
Prior Authorization process change for Mercy Care DCS CHP, Mercy Care Complete Care, Mercy Care Long Term Care and Mercy Care DD


Applicable To: Mercy Care Complete Care, Mercy Care Long Term Care, Mercy Care DCS CHP and Mercy Care DD

In an effort to streamline the Prior Authorization process for Mercy Care DCS CHP, Mercy Care Complete Care, Mercy Care Long Term Care and Mercy Care DD members, Mercy Care will be removing the Mercy Care DCS CHP Prior Authorization Grid effective May 5, 2022 and will be utilizing the Mercy Care Prior Authorization Grid for all Medicaid members. Mercy Care will also be adjusting the Mercy Care Prior Authorization grid to require authorizations for all member under the age of 18 for the following codes effective May 5, 2022:
 
J0401, Q2028, 57106, 57107, 57109, 57110, 57111, 57291, 57292, 57530, 57531, 57545, 58240, 58572, 58575, 58720, 58940, 58943, 90867, 90868, 90869, 90870, C1789, C1813, C2622, G9355, G9356, L7900, L7902, L8000, L8001, L8002, L8015, L8030, L8031, L8032, L8039, L8600, 19110, 19300, 19301, 19302, 19303, 19304, 19305, 19306, 19307, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 51925, 54120, 54125, 54130, 54135, 54300, 54304, 54328, 54332, 54336, 54420, 54430, 54435, 54520, 54530, 55899, 67950, 98925, 98926, 98927, 98928, 98929, 98940, 98941, 98942, 98943, G2067, G2068, G2069, G2070, G2071. G2072, G2073, G2074, G2075, L8033, 41115, 41010, and 40819
 
Mercy Care will also require a Prior Authorization for the following codes for all members regardless of age:
 
15788, 15789, 15792, 15793, 54163, 54162 and 54161
 
Please ensure you are looking for variance details when reviewing authorizations.
 
You may find a copy of the Mercy Care Prior Authorization Grid by using the link below:
 
 
Please 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!



www.MercyCareAZ.org