Please do not include decimal points in diagnosis code.
FOR MEDICAL PROFESSIONAL USE ONLY
PRIOR AUTHORIZATION INSTRUCTIONS
For pharmacy authorization requests, visit our Pharmacy Benefit Manager (PBM) website, MeridianRx. (This will open in a new window).
Requests for medical oncology and radiation therapy services should be routed through HealthHelp. A complete list of procedure codes requiring review by HealthHelp are available at portal.healthhelp.com/Meridian. Requests can be submitted through the HealthHelp website, by phone 888-285-0562, or fax 888-203-7271.
For training tools, submission options and user guides, click here.
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