Prior Authorization List for MMCP / MCHP
FOR MMCP: All Out-of-Network services and all services indicated below require authorization
FOR MCHP: Only the services indicated below require authorization
For services that require authorization, all MHN contracted providers must request authorization electronically as follows:
- Clinically credentialed providers - via EpicCare Link
- MHN contracted providers, but not clinically credentialed – via PlanLink
- MHS employed physician offices - via Epic Hyperspace
Non-participating providers should use our Authorization Request Form
For questions about requesting authorization electronically, please contact CCP at PlanLink@ccpcares.org. We would be happy to help you.
| Admission Inpatient |
| Elective Surgical Inpatient Admission |
Elective Medical Inpatient Admission |
| Non-elective (Emergency) Admission |
Inpatient Rehabilitation Admission |
| Skilled Nursing Facility Admission |
| Admission Observation |
| Hospital Observation Services ( for any reason ) |
Admission / Discharge Same Day |
| Home Health |
| Skilled Nursing Visits |
Home Respiratory Therapy Visits |
| Home Social Worker Visits |
Home Health Aide Visits |
| Physician Home Visits |
Private Duty Nursing |
| Personal Care Services |
| Hospice |
| Hospice Outpatient At Home / ALF / SNF |
Hospice Inpatient |
| Diagnostic and Lab Testing |
| Cardiac Event Monitoring |
CT Scan |
| Cta and Calcium Scoring |
Genetic Testing |
| Growth Evaluation & Tx For Hormone Therapy |
MRI |
| MRA |
PET Scan |
| Sleep Study |
| Durable Medical Equipment( medical and surgical supplies do not require authorization) |
| Bone Growth Stimulator |
Clinitron and Electric Beds |
| CPAP and BIPAP Machines |
Diabetic Shoes |
| Custom Wheelchairs |
Electric Wheelchairs / Scooters |
| Wheelchair Accessories |
Insulin Pumps and Supplies |
| Enteral Nutrition |
Patient Lifts |
| Wound Vac Pumps |
| Maternity |
| Obstetrical Care— All Sonograms, Pre-natal Procedures and Delivery |
| Nutritional Services |
| Nutritional Consulting |
Nutritional Supplements / Nutrition Formulas / Enteral Nutrition |
| Orthotics And Prosthetics |
| Custom Orthotics |
Limb and Torso Prosthetics |
| Prosthetic Custom Eye, Surfacing & Fitting |
| Transportation |
| Non-emergent Ambulance Services |
Air Ambulance |
| Invasive Procedures |
| Capsule Endoscopy |
Cesarean Delivery |
| Chemodenerve Eccrine Glands |
Circumcision (Auth Required If Age > 1 Year) |
| Denervation |
Epidural Injection for Lysis |
| Epidural Injection for Pain |
Hormone Pellet Implant |
| Hyperbaric Treatment ( Wound Care Center only ) |
Oral Arthroscopy |
| Oral Splint |
Oral Surgery |
| Spider Vein Therapy |
Spider Vein Therapy - Injection / Laser |
| Total Disc Arthroplasty (Artificial Disc) |
Virtual CT Colonoscopy |
| Cosmetic / Plastic / Reconstructive Procedures |
| Adjacent Tissue Transfer / Rearrangement / Repair |
Bariatric Surgery |
| Canthoplasty |
Correction of Lid Retraction |
| Dermatological Procedures |
Eyelid, Excision and Repair |
| Foot and Toes Reconstruction |
Gastric Restrictive |
| Gastric Restrictive, Port Component |
Hand and Fingers Reconstruction |
| Head ( skull, face, TMJ ) Reconstruction |
Humerus and Elbow Reconstruction |
| Keratoprosthesis |
Knee, Arthroplasty, Total |
| Lip, Repair |
Mastectomy Proc / Repair, Reconstruction |
| Mastoid Surgery Revision |
Neck and Thorax Reconstruction |
| Nose, Repair |
Ocular Adnexa, Strabismus Surgery |
| Palatoplasty for Cleft Palate |
Pelvis and Hip Reconstruction |
| Penile Repair |
Skin Flaps and Grafts |
| Testicular Prosthesis Insertion |
| Transplant |
| Amniotic Membrane |
Bone- Autograft for Spine Surgery |
| Bone Marrow |
Cornea |
| Eye |
Heart |
| Heart-Lung |
Intestine |
| Kidney |
Liver |
| Lung |
Ovarian |
| Pancreas |
Pancreatic Islet Cells |
| Peripheral Stem Cells |
Skin |
| Tissue |
