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

The New Pre-Service Medical Authorization Form is LIVE! Meridian has created a universal form to improve efficiencies for the authorization process. The form is user friendly, and provides faster decision making and turnaround time. Learn how to submit an authorization by reading or downloading the forms below.

Standard Fax Submission (Last Updated: 6/2/2017)

Electronic Fax Submission EMR (Last Updated: 6/2/2017)

Electronic Fax Submission Non-EMR (Last Updated: 6/2/2017)

Prior Authorization Rules for MeridianComplete - Michigan Providers

Prior Authorization Rules for MeridianCare - Michigan and Ohio Providers

PRIOR AUTHORIZATION FORM

ALL EMERGENT ADMISSION REQUESTS ARE REVIEWED WITHIN A 24 HOUR PERIOD

* INDICATES REQUIRED FIELD


MEMBER INFORMATION

REQUESTING PROVIDER INFORMATION

SERVICING PROVIDER / FACILITY INFORMATION

ALL CLINICAL DOCUMENTATION MUST BE ATTACHED TO AVOID PROCESSING DELAYS

SERVICE INFORMATION

Please select either, an Admission – Acute & Subacute, OR Elective Services - Setting AND Service Type.

OR
AND

AUTHORIZATION REQUEST







+Add Diagnosis Code

+Add Procedure

Provider Notes

250 character max

ALL REQUIRED FIELDS MUST BE COMPLETE AND SUBMISSIONS MUST INCLUDE
CLINICAL DOCUMENTATION, AS INCOMPLETE REQUESTS WILL BE REJECTED

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.
Illinois HFS Disclaimer: An authorization is not 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 user, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.

Page Last Modified: 5/4/2017 8:51:37 AM