POST-SERVICE MEDICAL NECESSITY APPEALS
Date: 09/21/22
Meridian is excited to announce process enhancements for submitting post-services medical necessity appeals. We’ve added a dedicated post-service appeal form (PDF) for convenience.
Member Standard Appeal – at any time, a member or authorized designee may submit an appeal for authorization or termination of services. If a provider appeals on behalf of a member before services are rendered, they must obtain written authorization on the member’s behalf as outlined in Section 3 of the provider manual (PDF).
Provider Appeals, commonly referred to as Medical Necessity Appeals, are related to authorization requests denied in whole or in part for medical necessity. Provider appeals are submitted post-service on the provider’s behalf.
Medical necessity appeals of denied authorizations submitted after the service has occurred do not need written authorization from the member. These are Post Service Medical Necessity Appeals, which may be submitted before or after the related claim has been filed. Please note that Post Service Medical Necessity Appeals must be submitted after the service has been rendered.
Providers must have a denied or partially denied authorization for a qualified Medical Necessity Appeal. If a claim is denied for authorization and the authorization number is unavailable, the claim denial must be filed as a claim dispute as outlined in Section 6, page 44 of the provider manual.
Meridian’s appeal and claim dispute process is available to all in-network and out-of-network providers. Post-Service Medical Necessity Appeals must be filed in writing within 90 days of the service. Providers may appeal by mail or fax via the Medical Necessity Appeal Form.
Submitting Appeals – Faxing is the preferred method to submit Post Service Medical Necessity Appeals. Appeals can also be mailed to the addresses noted.
Non-Behavioral Health Services | Pharmacy | Centene Advanced Behavioral Health Services (CABH) |
|---|---|---|
Fax: 833-383-1503
Mail: Attn: Medical Necessity Appeals Meridian PO Box 716 Elk Grove Village, IL 60009
| Fax: 833-433-1078
Mail: MeridianRx Attn: Appeals & Grievance 1 Campus Martius, Suite 750 Detroit, MI 48226
| Fax: 866-714-7991
Mail: CABH Appeals Department |
For Behavioral Health per Diem claims, HFS billing guidelines require a claim to be billed with covered and non-covered days if any days are initially denied as non-medical necessary. If the provider appeals the no covered days and the denial is overturned, the provider must send in corrected claims with all covered days to receive payment for the days that were overturned on appeal.
If any claim denies for no authorization due to the provider not requesting an auth, this would be considered a claims dispute, and the claim dispute process outlined in the provider must be followed. Sending a claim dispute in as a post-service medical appeal will be returned to the provider to follow the correct procedure. The claim dispute time frame of 90 days will not be extended if the provider fails to follow the proper process. As a reminder, Meridian does not generally allow for retro authorization review when the provider fails to secure an authorization before rendering service.
If you have questions or need assistance, please contact your assigned Provider Network Support Specialist (PNS II), Provider Engagement Administrator, or use the Provider Intake form.