How to Fill Out and Submit the Mercy Care Prior Authorization Form

The Mercy Care prior authorization form is a service-specific PDF that providers download from the Mercy Care website, complete with member, provider, coding, and clinical information, and fax to the number assigned to that service line. Mercy Care handles these requests for members of Arizona’s Medicaid program (AHCCCS),¹ and under federal rules in effect as of 2026, it must issue a standard decision within seven calendar days and an expedited decision within 72 hours.²

Pick the Right Form for the Service

Mercy Care publishes separate prior authorization forms for different service types, and using the wrong one is the quickest way to have a request bounced before any clinical review happens. All of the forms are available as downloadable PDFs on the Mercy Care provider forms page.³

The Standard Request Form covers most outpatient services and hospital admissions. The form itself states it should not be used for DME, home health, therapy, ECT, psychological testing, or inpatient behavioral health.⁴
The DME Request Form is for durable medical equipment such as wheelchairs, CPAP machines, or prosthetics.
The Therapy and Home Health Request Form covers physical, occupational, and speech therapy as well as home health services.
Behavioral health has multiple forms: ABA services, adult behavioral health residential facilities, children and adolescent behavioral health placements, and substance use residential treatment each have their own.³
The Clinical Trials Form is for experimental or investigational treatments conducted under an approved clinical trial.

Pull the current version from the website every time rather than reusing a saved copy. Fields and requirements change, and an outdated form can be rejected automatically.

Gather Everything Before You Open the Form

A single missing field, especially an NPI or a diagnosis code, is enough to send the request back without clinical review.

Member Information

You need the member’s full legal name, AHCCCS member ID, date of birth, and phone number.⁴ Verify the member ID against AHCCCS eligibility records. A transposed digit produces a mismatch that stalls the request.

Provider Information

The form has separate sections for the ordering provider and the servicing provider or facility. Each requires name, address, tax identification number, ten-digit National Provider Identifier, phone number, fax number, and a contact name.⁴ The NPI is the standard identifier assigned to every healthcare provider under HIPAA.⁵ Enter the fax number carefully. Mercy Care returns the determination notice to the fax number you listed.

Diagnosis and Procedure Codes

Every request needs at least one ICD-10 diagnosis code and at least one CPT or HCPCS code identifying the specific service or equipment.⁴ ICD-10 codes classify diagnoses.⁶ CPT codes are five-digit numeric codes covering most physician services; HCPCS Level II codes use a letter followed by four digits and generally cover equipment, supplies, and services outside a physician’s office.⁷ Mismatches between the diagnosis and the requested service drive a large share of denials.

Clinical Documentation

The form includes a checklist. Attach the items that apply: physician notes, specialist notes, lab results, diagnostic test results, radiology results, assessments, and current medication lists.⁴ Notes showing that less intensive treatments were tried and failed, or explaining why they would be inappropriate, carry weight in the clinical review. Mercy Care’s provider manual requires that all submitted documentation be dated no earlier than three months before the request.⁸ Order the attachments to match the checklist so the reviewer can match them quickly.

Filling Out the Form

The Standard Request Form is a fillable PDF. At the top, enter the date, the total number of pages you are submitting (form plus attachments), and the requestor’s name, phone number, and fax number.⁴

Complete the member section, the ordering provider section, and the servicing provider or facility section. Then mark the request as non-urgent or urgent. If you select urgent, write a reason explaining why a standard timeframe could seriously harm the member’s health. Without that written reason, the request defaults to the standard timeline no matter what box you checked.

The services section is the heart of the form. Enter each CPT or HCPCS code with its corresponding ICD-10 code, then write a brief clinical rationale. Keep the rationale specific to this patient and this request, not a generic description of the procedure. Check the boxes for the supporting documents you are attaching. A physician or authorized clinical representative must sign and date the form. Unsigned or undated forms are treated as incomplete and returned without review.

How to Submit the Form

Mercy Care no longer accepts prior authorization requests through its own web portal.⁹ The primary submission method is fax, and the number depends on the service.¹⁰ Sending to the wrong line creates routing delays that eat into the review clock.

Behavioral health inpatient requests for members with a serious mental illness designation: 855-825-3165.
DES/DDD member requests: 800-217-9345.
Nutritional therapy: fax to Aveanna Healthcare at 844-754-1345, which coordinates with Mercy Care.
Radiology: submit through Availity rather than by fax, per Mercy Care’s provider manual.⁸

Check the medical prior authorization page for the current number that matches your request type before sending.¹⁰

After faxing, confirm the transmission succeeded and keep the confirmation page. If a determination or extension notice does not arrive within a few business days, follow up. A failed fax is invisible to Mercy Care.

When to Expect a Decision

Federal regulations that took effect January 1, 2026, cut the standard decision window for Medicaid managed care plans to seven calendar days from receipt of the request. Before 2026, the limit was 14 calendar days.²

When the provider indicates, or Mercy Care determines, that following the standard timeframe could seriously jeopardize the member’s life, health, or ability to regain function, the plan must decide within 72 hours.²

Mercy Care can extend either deadline by up to 14 additional calendar days if it needs more clinical documentation or if the member or provider requests the extension. When it extends, it must notify the provider and member in writing, explain why, and specify what additional documentation it needs. If that documentation does not arrive by the extension deadline, Mercy Care may deny the request on that date.⁸

Once a decision is made, Mercy Care sends a written notice to both the provider and the member. A denial notice must explain the reasons, the right to appeal, how to request an expedited appeal, and how to keep receiving services during the appeal.¹¹

Why Requests Get Denied

Denials split into administrative and clinical. Administrative denials happen before anyone evaluates medical appropriateness. Clinical denials happen after review, when the records do not support coverage criteria.

The most common administrative problems:

Using the Standard Request Form for a service that has a dedicated form (DME, therapy, behavioral health).
Missing or mismatched codes. The diagnosis does not clinically support the procedure, or the CPT/HCPCS code does not match the service described.
Incomplete provider information. A missing NPI, TIN, or fax number stalls the request because Mercy Care cannot identify or reach the ordering provider.
No signature or no date. Both are required, and the form is returned without review if either is missing.

Clinical denials usually come down to documentation. The reviewer may find that records do not show more conservative treatments were tried first, that the clinical notes are too old to reflect current condition, or that the diagnosis does not meet coverage criteria for the requested service. Documentation older than three months before the request date does not meet the manual’s requirement.⁸

If another insurer has already approved the service through its own medical necessity review, Mercy Care coordinates benefits with that payer and does not require a second prior authorization.⁸

If the Request Is Denied

A denial is not the end. Providers and members can appeal through Mercy Care, and if the internal appeal is unsuccessful, request a state fair hearing through AHCCCS.¹²

Peer-to-Peer Review

Before filing a formal appeal, the ordering provider can often request a peer-to-peer review: a phone call between the treating physician and a Mercy Care medical director. It gives the provider a chance to explain clinical reasoning directly and clarify anything that was unclear in the written documentation. A peer-to-peer is generally available only before a formal appeal is submitted. Once the appeal process starts, the option typically closes.

Filing an Appeal

To appeal, contact Mercy Care’s Grievance and Appeals Department or call customer service. The denial notice lists specific instructions and deadlines. Mercy Care generally has 30 days to resolve a standard appeal. If waiting 30 days could seriously harm the member’s health, the member or provider can request an expedited appeal, which Mercy Care must resolve within three working days.¹²

Continuing Services During the Appeal

Members already receiving a service that Mercy Care wants to reduce, suspend, or terminate may be able to keep receiving it during the appeal. To preserve that right, the appeal must be filed before the effective date of the reduction or termination. If fewer than ten days separate the notice date and the effective date, the member has ten days from the notice date to file. If the appeal is ultimately unsuccessful, the member may owe for services received during the appeal period.¹²

State Fair Hearing

If Mercy Care upholds the denial after the internal appeal, the member can request a state fair hearing through AHCCCS. The notice from the internal appeal explains how. A state fair hearing is an independent review conducted outside Mercy Care and is the final level of administrative review available to AHCCCS members.¹¹

1
Mercy Care. Become a Member – Medicaid
2
eCFR. 42 CFR 438.210 – Coverage and Authorization of Services
3
Mercy Care. Provider Forms
4
Mercy Care. Prior Authorization Standard Request Form
5
Centers for Medicare & Medicaid Services. National Provider Identifier Standard
6
Centers for Disease Control and Prevention. ICD-10-CM
7
Centers for Medicare & Medicaid Services. Healthcare Common Procedure Coding System
8
Mercy Care. Provider Manual
9
Mercy Care. Provider Portal
10
Mercy Care. Medical Prior Authorization
11
eCFR. 42 CFR 438.404 – Timely and Adequate Notice of Adverse Benefit Determination
12
Arizona Health Care Cost Containment System. Grievance and Appeals