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 |