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Medical Policies

These documents are for informational purposes only and as such, it is not an authorization, certification, explanation of benefits or a contract.

Receipt of benefits is dependent on the satisfying the terms and conditions of coverage. Eligibility and benefit coverage are determined by the terms of the member’s plan in effect on the date the services are rendered.

MercyCare’s medical policies are developed with the assistance of medical professionals. They are based on a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and current community medical practices. The areas of medical practice, information and technology change constantly, MercyCare reserves the right to review and update its medical policies at its discretion. The medical policies are intended to be a resource to MercyCare, our health care providers and members. They are not a guarantee of coverage and compliance with the policies does not guarantee payment. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care.

CN-062.15 Skilled Nursing Facility

CN-001.05 Cross Linking

MA-028.02 MCD Prenatal Care Coordination

MA-036.04 Transplant

MS-001.006 Referrals Case Closure

MS-002.04 Denial Monitoring Process

MS-004.13 File Management Policy

MS-018.01 NSA Emergency Admit without Notification

MS-020.18 QHM Staff Availability

MS-027.24 Appropriate Licensed Health Professionals

MS-028.27 Denial Notification Policy and Procedure

MS-038.30 Utilization Management Decisions Determinations

MS-044.11 Potential Quality Issues as Identified from Inpatient Reviews

MS-047.27 UM Timelines Decision and Notification

MS-048.26 Interrater Reliability

MS-052.19 Transition to Other Care

MS-059.20 New Technology Assessment

MS-071.22 Prudent Lay Person and Emergency Services Policy

MS-077.31 Referral Policy

MS-078.01 Provider Appeals (previous PR.007)

MS-101.12 Durable Medical Equipment and Supplies Policy

MS-102.09 Low Back Pain Referrals

MS-103.10 Coordination of Care at Discharge

MS-104.09 High Tech Radiology Procedures

MS-106.09 Advance Care Planning

MS-107.09 Moral or Ethical Objection to Providing Care to a Member

MS-108.08 Restraint Policy

MS-109.07 Transgender Services Gender Reassignment-RETIRED

QI-007.05 Quality Event Process