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.
Please do not include decimal points in diagnosis code.
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
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