Prior Authorization
The information on this page is specific to the Meridian Medicaid Plan. Visit the Prior Auth Check tools below for our family of plans.
Prior Auth Check Tools: Ambetter | Medicaid | Medicare-Medicaid Plan | Wellcare | YouthCare
Prior authorization (PA) is required before certain services are rendered to confirm medical necessity. No PA is required for emergency or transportation services. All services for out-of-network providers, except emergency services, require prior authorization. Criteria utilized in decision making can be accessed through the secure provider portal.
How to Request a Prior Authorization
- Determine if a PA is needed with the Meridian Prior Auth Check tool.
- Submit PAs electronically through the secure provider portal for the most convenient service.
- First-time users: Create a new portal account for 24/7 access to patient lists, health information, and plan eligibility & the ability to submit and check the status of claims and authorizations.
- Submit PAs via fax using the following forms:
- Submit PAs through Meridian vendor solutions partners as noted in the table below.
| Vendor Solutions | Vendor Links |
|---|---|
| Dental | Envolve Dental |
| MRA, MRI, PET, CT Scans, and Cardiac Imaging | Evolent |
| Pain Management | Evolent |
| Speech, Occupational and Physical Therapy | Evolent |
| Musculoskeletal Services | Evolent |
| Oncology/Supportive Drugs for Members Age 18 and Older | Evolent Specialty Services |
| Pharmacy | covermymeds |
| Post-acute facility (SNF, IRF, and LTAC) | CareCentrix Fax: 877-250-5290 |
| Non-Emergent Non-Ambulance Transportation | MTM |
- Guidance about services requiring PA is in the Meridian Provider Manual.
- Use the Meridian Prior Auth Check tool for code-specific requirements.
Notification of all review determinations is provided verbally and/or in writing to providers and members within the following established time frames:
- Non-Urgent Pre-Service Review (Standard): Within 4 days of receipt of the request
- Urgent Pre-Service Review (Expedited): Within 48 hours of the request
- Urgent/Concurrent Review: Within 24 hours of the request. 72 hours if clinical information is incomplete or is not included.
Decisions determine the medical necessity of a service and are not a guarantee of payment. Claims payment is determined by the member’s eligibility and benefits at the time the services are rendered. Copies of the criteria utilized in decision making can be obtained in the provider portal when an electronic authorization request is submitted.
Treating physicians who would like to discuss a utilization review determination with a decision-making Medical Director may do so at any time during the review process by contacting the Utilization Management department at the member’s health plan. A peer-to-peer discussion performed after an adverse determination may result in an overturn if requested within 5 calendar days of the initial notification.
- Meridian Medicaid Plan: Utilization Management
833-541-2297
The information on this page is specific to the Meridian Medicaid Plan. For utilization management information for our family of plans, please consult each plan’s provider manual or use the contact information below:
- Ambetter: Provider Services
855-745-5507
- Meridian Medicare-Medicaid Plan: Utilization Management
855-580-1689
- WellCare: Provider Services
855-538-0454
- YouthCare HealthChoice: Utilization Management
844-289-2264