For retail/pharmacy authorization requests, visit the Our Plans page. Then, select your state and line of business. Under Provider Resources, select Documents & Forms. There you will find the Medication Prior Authorization Request Form.

FOR MEDICAL PROFESSIONAL USE ONLY

PRIOR AUTHORIZATION INSTRUCTIONS

Effective 12/18/2017, the Online Medical Prior Authorization Form has been UPDATED!
The Service Information fields have changed.

 

First, the user will select Place of Service, which will be Inpatient, Outpatient or Home.
Second, the user will select the Service Type, which is the type of service being rendered.
Third, the user will select Place of Service Description, which provides a list of facility types to select from.

 

Click here for a brief training video on how to submit an authorization request, frequently asked questions, and links to all of our prior authorization requirements for Michigan and Illinois. 

 

For users who are selecting FAX SUBMISSION, please continue to PRINT confirmation cover page and SEND to MeridianHealth with applicable documentation.

MI Fax: 313-309-8580

IL Fax: 312-508-7299

PRIOR AUTHORIZATION FORM

ALL EMERGENT ADMISSION REQUESTS ARE REVIEWED WITHIN A 24 HOUR PERIOD

* INDICATES REQUIRED FIELD

MEMBER INFORMATION

Invalid Date

REQUESTING PROVIDER INFORMATION

SERVICING PROVIDER INFORMATION

SERVICING FACILITY INFORMATION

Please do not use GROUP NPI information in this section.

ALL CLINICAL DOCUMENTATION MUST BE ATTACHED TO AVOID PROCESSING DELAYS

SERVICE INFORMATION


Invalid Date
OR
Invalid Date
AND
Invalid Date

Invalid Date
OR
Invalid Date
Invalid Date

AUTHORIZATION REQUEST

Invalid Date
Invalid Date
Invalid Date
Invalid Date
Invalid Units

+Add Diagnosis Code

+Add Procedure

Provider Notes

250 character max


Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policies and procedures. Other rules may apply.

IL HFS Disclaimer: An authorization is not a guarantee of payment. Providers must enroll with Illinois Department of Health and Family Services and obtain a valid Medicaid ID number prior to the date of service to qualify for reimbursement for services.  Claims submitted without valid Medicaid ID will be rejected and are not payable. If you have not enrolled and require a Medicaid ID number you may visit the HFS website or the IMPACT website at: https://www.illinois.gov/hfs/impact/

Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996.  If you are not the intended recipient, any use, distribution or copying is strictly prohibited.  If you have received this facsimile in error, please notify us immediately and destroy this document.

I attest this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain.

A fax submission allows the Prior Authorization Form to be printed and submitted via fax

A electronic submission allows clinical attachments to be made to the Prior Authorization Form and allows the form to be submitted online without printing or faxing

If the provider that will be rendering the service is an individual practitioner, please list the individual NPI. If the provider that will be rendering the service is part of a group/organization, please list the applicable Type II NPI.

Please enter Individual NPI belonging to the requestor.

Estimated Date of Confinement/Estimated Date of Delivery

Last Menstrual Period

Estimated Date of Confinement

Please list the appropriate Type II NPI for the specific location where the service is being rendered

Page Last Modified: 12/18/2017 1:09:19 PM