Date:March 2017Annual Notice of Utilization Management Affirmation

Affirmation Statement:

At the Mercy Physician Association (MPA) Site 459 we affirm that:

  1. Utilization Management decision-making is based medical necessity, which includes appropriateness of care and service and existence of available benefits.
  2. MPA does not specifically reward health plan staff, practitioners or other individuals for issuing denials of coverage or service or care.
  3. MPA does not have incentive programs that are utilized to encourage decisions that result in under utilization.

MPA also affirms that there is no conflict of interest between the Mercy Physician Association and the utilization management decision makers.

Criteria Notice

Mercy Physician Association uses the most current version of the following criteria for benefit determination:

  1. McKesson InterQual Level of Care Criteria for medical and mental health inpatients
  2. McKesson InterQual Procedures Criteria for determining medical necessity of surgical procedures
  3. McKesson InterQual Imaging Criteria
  4. McKesson InterQual Molecular Criteria
  5. American Society of Addiction Medicine (ASAM) for Substance Use Disorder
  6. NCCN Clinical Guidelines/Drug and Biological Compendium(chemotherapy guidelines) 1A; 2A; 2B
  7. Federal Drug Administration (FDA) prescribing guidelines, including indicated uses and dosing
  8. For any requests not eligible for review by the above listed criteria, MPA shall use the medical policies developed by Blue Cross Blue Shield HMO of Illinois as adopted and approved annually by the MPA UM Committee
  9. The member’s certificate of health care benefits
  10. The member’s schedule of benefits.
  11. MPA Medical Group Policies adopted and approved by a physician committee.

These criteria are updated annually. The criteria and policy are reviewed and approved annually by the Mercy Physician’s Association Utilization Management Committee

You may contact Mercy Physician Association to request a copy of a specific set of criteria be faxed or mailed to you.

The entire set of criteria can be reviewed at our office. Please contact Mercy Physician Association at 1-877-642-4936 if you wish to review these criteria.

Care Coordination Program: Complex Case Management, Disease Management (Asthma & Diabetes), Case Management

The Care Coordination Program is designed to provide a level of support for your specific situation and coordination for your care in collaboration with your PCP and an interdisciplinary care team. The Care Coordination Program consists of Complex Case Management, Disease Management (Diabetes& Asthma), and Case Management.You may self refer, your PCP may refer you or you may be identified by MPA for evaluation for one of our programs. You may choose to Opt out of any of these programs.

You may contact MPA at 877-642-4936 to refer a member or self-refer yourself for evaluation for a Care Coordination Program.

Notice of MPA Staff Availability

Mercy Physician Association business hours are Monday through Friday 8:00am to 4:30 pm CST.

Toll Free Phone Numbers: MPA Customer Service: 1-877-642-4934

Quality Health Management: 1-877-642-4936 FAX Number: 1-608-758-7726

TDD/TTY Services: 1-800-947-3529 for the deaf, hard of hearing and speech impaired.

  • Confidential personal voice mail and FAX receiving services available 24 hours per day, 7 days per week.
  • 24 Hour toll free phone service
  • FAX and non-urgent communications received after business hours will be responded to on the next business day.
  • Language Assistance & Language Translators for members are available & can be accessed through the MPA Customer Service Toll free number.