Utilization Management


NOTE: Failure to request and receive a prior authorization from Children's Mercy Pediatric Care Network (PCN) may result in denial of payment. All claims are subject to verification of eligibility and benefits. Authorization does not guarantee payment. See the Prior Authorization Quick Guide for Missouri Pediatric Care Network Members.

Inpatient Admissions: Scheduled and non-emergent inpatient admissions require notification and clinical information at least two (2) business days prior to the services being rendered. Emergent services require notification to the PCN within ten (10) business days after admission. The participating providers are responsible for communication of clinical information to the PCN. Newborns remaining in the hospital after the mother is discharged require an authorization for continued inpatient services.

Medical Review Process: Medical review is conducted to confirm the medical necessity of treatments or services rendered, as well as the appropriateness of the care setting. Medical review requires evaluation of specific clinical information that is obtained from onsite reviewers, over the telephone or from written communication. PCN Care Navigators compile all pertinent clinical information gathered from the treating practitioners/staff, review the information using medical necessity decision criteria and consider individual patient needs, as well as the local healthcare delivery system. Once the review is complete, the Care Navigator confirms medical necessity, the appropriateness of the care setting, and authorizes the requested service. When medical necessity and/or appropriateness of the care setting cannot be confirmed, the case is referred to a Board Certified physician for review. Any denial decisions are done by a Board Certified physician.

If you would like a copy of the criteria, please click on the associated links below or contact the PCN Prior Authorization Department at 1-877-347-9367 for MO PCN Members and 1-833-802-6427 for KS PCN Members or fax your request to 1-888-670-7260. A written copy of the criteria will be mailed or faxed within three (3) business days of your request. Cosmetic Procedures • Private Duty Services

Contacting UM: Medical review staff members are available for questions related to prior authorization and coverage: Monday – Friday, 8:00am – 5:00pm. They can be reached by toll free phone at 1-877-347-9367 for MO PCN Members and 1-833-802-6427 for KS PCN Members or toll free fax at 1-888-670-7260. The same toll free phone number and toll free fax number are available 24/7 for communication of utilization management issues. Information left after normal business hours should include: caller's name and contact number, member name, member ID number, and the reason you are calling. The request will be responded to the next business day.

Statement on Incentives: The Children's Mercy Pediatric Care Network makes all review decisions based only on the appropriateness of care and service, the existence of coverage for the member, and his or her unique health needs. PCN does not specifically reward providers or other individuals for issuing denials of coverage. Financial incentives for UM decision making do not encourage decisions that result in underutilization.

If you would like to discuss a decision with a PCN Medical Director, you may call the Prior Authorization Department at 1-877-347-9367 for MO PCN Members and 1-833-802-6427 for KS PCN Members and ask to speak with the Medical Director.

Appeals Information:

Jump to:


- Utilization Management

- Care Integration Programs

- Case Management

- Clinical Practice Guidelines

- Disease Management

- Lead

- OB Case Management


UM Resources

Referral Form

To refer a PCN member to a Care Navigator, fill out this form or call Care Integration:
Toll Free MO PCN Phone:
1-877-347-9367
Toll Free KS PCN Phone:
1-833-802-6427
Toll Free Fax:
1-888-670-7260

Prior Authorization Quick Guide for Missouri Pediatric Care Network Members

office resource

Utilization Management Plan

Member Handbooks:
Provider Manuals:
Clinical Determination Guidelines:
PCN Care Integration
(888) 670-7262

PCN Prior Authorization Fax
(888) 670-7260

PCN Prior Authorization Phone
(877) 347-9367


See all resources





Care Integration Programs


The Pediatric Care Network (PCN) offers a comprehensive care integration program, consisting of complex case management (CM), disease management (DM), care coordination and population health to eligible members. The care integration program focuses on preventive health and enhancing and coordinating a member’s care across an episode or continuum of care; negotiating, procuring and coordinating services and resources needed by members and families with complex issues; facilitating care transitions across care settings; ensuring and facilitating the achievement of quality, clinical and cost outcomes; intervening at key points for individual members; addressing and resolving patterns of issues that have negative quality or cost impact and creating opportunities and systems to enhance outcomes. Through data analysis and identification of high cost or high risk trends, PCN continually assesses the characteristics and needs of the population and sub-populations being managed to identify opportunities to enhance and/or modify its care integration program. This includes children with special needs, disabilities, and other complex health issues. Disease management interventions focus on two chronic conditions that are relevant to the pediatric population; asthma and diabetes. PCN assesses all program interventions and resources to determine if changes are needed to better meet the needs of the population.

The goal of the care integration program is to help members sustain or regain optimal health in the right setting and in a cost effective manner. This is achieved through the well-coordinated efforts between the program staff and patient centered medical home practices. Including the primary care providers (PCP) in this integration assures continuity of care and alignment for improving health outcomes. The Care Integration staff work closely with the PCPs to assess the population’s needs, determine available benefits and resources, and develop and implement specific interventions to meet the population needs.

The objectives of the care integration program are to:
  • Assist members in sustaining or achieving an optimal level of wellness and function by facilitating timely and appropriate health care services
  • Promote strong member/Primary Care Provider relationships for coordination and continuity of care, using Patient Centered Medical Home concepts
  • Reduce inappropriate inpatient hospitalizations and utilization of emergency room services
  • Promote clinical care that is consistent with scientific evidence and member preferences
  • Ensure the integration of medical and behavioral health services
  • Educate members in self-advocacy and self-management
  • Minimize gaps in care and encourage use of preventive health services
  • Achieve cost efficiency in the provision of health services while maximizing health care quality
  • Mobilize community resources to meet needs of members

Circumstances that warrant referral to the case management team include but are not limited to:
  • Presence of progressive, chronic, or life-threatening illness
  • Need for inpatient or outpatient rehabilitation
  • Terminal illness
  • High risk pregnancies
  • Acute/traumatic injury, or an acute exacerbation of a chronic illness
  • Complex social factors
  • Children with Special Health Care Needs
  • Multiple hospitalizations or emergency room visits
  • Elevated lead levels

To refer a patient for PCN's case management services, call Care Integration at 1-877-347-9367 for Missouri members
and 1-833-802-6427 for Kansas members or use this referral form.

Case Management and
Disease Management

Referral Form

To refer a PCN member to a Care Navigator, fill out this form or call Care Integration:
Kansas Members
1-833-802-6427
Missouri Members
1-877-347-9367

Care Integration Program Guide

office resource

Case Management Quick Guide

office resource

Childhood Blood Lead Testing and Follow-Up Guidelines

office resource

HCY Lead Risk Assessment Guide

(Missouri)
office resource

Preventing Lead Poisoning

Healthy Blue of Missouri
UnitedHealthcare Community Plan of Missouri

Lead Prenatal Assessment

office resource

See all resources





Case Management


  OB Case Management

  • In addition to our general case management program, we have a focused OB management program for high risk pregnancies. The following applies to our OB program:
  • The attending provider must submit a Pregnancy Notification Form (PNF) for all PCN members once pregnancy has been confirmed. This PNF is utilized for claim payment of OB services as well as screening by PCN Care Managers to determine a member's risk factors for the current or previous pregnancies.
  • Once the OB services have been authorized, all OB office visits and services, including two OB ultrasounds, are paid without additional authorizations. Non-stress tests (NST) do not require an authorization when performed by a participating provider.
  • Any additional services require additional authorization by the PCN Care Manager. The Care Manager may attend clinic visits and is the provider's primary contact for any OB related issues, such as home visits, education, and assessments for risk factors that may require a referral for social services interventions, non-compliant and/or transportation issues.
  • Once the delivery occurs the Care Manager may perform a site visit and assist the member with enrollment in WIC, HCY/EPSDT scheduling, continued medical care, birth control, and home health visits as individually appropriate.

  Lead

  • Childhood development and behavior can be affected by lead poisoning. Lead case management is offered to members with an elevated lead blood level above 10 ug/dL. The care manager will visit the home to identify the source of lead exposure for the member. After the source has been identified, the care manager will work with the family, primary care provider, local health department and community agencies to eliminate the member’s exposure to the lead source.
  •  
  • Provider / Office Resources

Disease Management


  • Children's Mercy Pediatric Care Network (PCN) offers Disease Management programs for on appropriate diagnosis, treatment, and management utilizing the Patient Centered Medical Home (PCMH) model and PCN medical home team. The PCN medical home team includes care navigators and population health management network representatives. PCN's Disease Management programs are based on nationally recognized evidenced-based guidelines that can be accessed on the PCN website: www.cmics.org/pcn  

    Member Eligibility:

    All PCN members with a diagnosis of, or at risk for, the following conditions are automatically enrolled in a disease management program.
    • Asthma
    • Diabetes
    • Major Depressive Disorder
    • Weight Management/Obesity

    Members can decline to participate at any time by calling PCN Care Integration at 1-877-347-9367 for Missouri members, and 1-833-802-6427 for Kansas members. PCN uses the following sources to identify and enroll members:
    • Data sources: claims or encounter data; utilization management or case management
    • Physician referral
    • Member self-referral

    What services are included?

    The Disease Management Programs for primary care providers create a unique partnership between the PCN medical home team, the providers, and the patient. The programs target best practices and underscore the patient-provider partnership, self-management skills and improved health care utilization. Additionally, the medical home team is available to work side-by-side with clinic staff to reinforce skills and foster behavior changes for effective disease management. Providers can refer members to the PCN care managers to reinforce self-management skills.

    Health Education

    The PCN care navigators provide health education for members, resources and support to self-manage their condition. Health education is designed to empower members to follow their prescribed treatment plan and develop a partnership with their providers. PCN's care navigators follow nationally recognized guidelines of care to teach self-management skills to reduce emergency room visits, hospital admissions and improve quality of life.

    PCN care navigators work with members through telephonic and in-person visits. They provide an array of educational handouts to reinforce self-management skills and provide support for medication management, lifestyle concerns, and management of comorbidities. The care navigators send providers quarterly reports about the member's progress.

    To refer a PCN member to a care manager, use the PCN Referral form or call Care Integration at 1-877-347-9367 for Missouri members, and 1-833-802-6427 for Kansas members.