Some services and medications need to be approved as “medically necessary” by Keystone Mercy before your PCP or other health care provider can help you to get these services. This process is called “prior authorization.”
Prior Authorization Process
- Your PCP or other health care provider must give Keystone Mercy information to show that the service or medication is medically necessary.
- Keystone Mercy nurses review the medical information. The nurses use clinical guidelines approved by the Department of Public Welfare to see if the service or medication is medically necessary.
- If the request cannot be approved by a Keystone Mercy nurse, a Keystone Mercy doctor will review the request.
- If the request is approved, we will let you and your health care provider know it was approved.
- If the request is not approved, a letter will be sent to you and your health care provider telling you the reason for the decision.
- If you disagree with the decision, you may file a Complaint or Grievance and/or request a Fair Hearing. See Complaints, Grievances and Fair Hearings for more information.
- You may also call Member Services for help in filing a Complaint, Grievance and/or Fair Hearing.
Services That Need Prior Authorization
- Services or Durable Medical Equipment (DME) received from providers or hospitals not in the Keystone Mercy network (except: tobacco cessation counseling sessions; emergency services; family planning services provided through Keystone First; and any Medicare-covered services from a Medicare provider if you have Medicare coverage)
- Non-emergency admission to a hospital
- Some medical or surgical procedures performed in a Short Procedure Unit (SPU) or Ambulatory Surgery Unit (ASU), either hospital based or free-standing, including but not limited to, the following:
- Steroid injections or blocks administered for pain management
- Obesity surgery
- Binding or removing veins
- All non-emergency plastic or cosmetic procedures (other than those immediately following traumatic injury) including, but not limited to, the following:
- Plastic surgery for eyelids
- Breast reduction
- Plastic surgery of the nose
- Admission to a nursing or rehabilitation facility
- Therapy services, after the first 24 visits, including outpatient physical, occupational and speech therapy services, and cardiac and pulmonary rehabilitation services with a Keystone Mercy network provider
- Home Health services, including infusion therapy, skilled nursing visits, home health aide visits, physical therapy, occupational therapy and speech therapy
- All DME rentals
- All DME purchases that cost more than $500 and:
- Tube feedings and nutritional supplements (Enterals)
- when the member is age 21 and over, or
- if the dollar amount is in excess of $200/month for members under the age of 21
- Diapers and/or pull-up diapers, when medically necessary, for members 3 years of age and over, when requesting:
- more than 200 generic diapers and/or pull-up diapers per month
- brand specific diapers, or
- diapers supplied by a DME provider
- Any service/product not covered by the Medical Assistance program
- Some outpatient diagnostic tests and procedures
- Chiropractic services with a Keystone Mercy network provider, after the first visit
- Hospice services
- Some specialty dental services
- PET and CT scans, MRI, MRA and Nuclear Cardiology
- Prescribed pediatric extended care center and medical daycare
- Ambulance transportation to and from prescribed extended care center and medical daycare
- Some formulary prescription drugs, all nonformulary prescription drugs, some over-the-counter non-prescription drugs, and some DME supplies obtained through a Keystone Mercy network pharmacy (e.g., glucometers)
- All transplant evaluations and consultations
- Air Ambulance transportation
As a Keystone Mercy member, you are not responsible to pay for medically necessary, covered services. You may, however, be responsible for a co-pay.
You may have to pay when:
- A service is provided without prior authorization when prior authorization is required or
- A service is provided by a provider who is not in the Keystone Mercy network and prior authorization was not given to see this provider (except for emergency services; family planning services provided through Keystone First; and any Medicare-covered services from a Medicare provider if you have Medicare coverage) or
- The service provided is not covered by Keystone Mercy and your provider told you that it is not covered before you received the service
Your health care provider can also bill you for co-pays that were not paid at the time you received the service. See If You Get a Bill or Statement and Co-payment Schedule.