Meridian Michigan Pre Approval Form – Fill Out and Use This PDF

No Prior Authorization (in or out of network)

Allergy Testing

Audiology Services and Testing (excluding hearing aids)

Barium Enema

Bone Densitometry Studies

Bronchoscopy

Cardiac Stress Test

Cardiograph

Chiropractic Services (in-network only*)

Colposcopy after an Abnormal Pap

DME/Prosthetics and Orthotics ≤ $1000 (in-network only*)

Echocardiography

Endoscopy

Gastroenterology Diagnostics

Intravenous Pyelography (IVP)

Life-Threatening Emergencies (ER Screening)

Mammogram and Pap Test

Myoview Stress Test

Neurology and Neuromuscular Diagnostic Testing

(EEGs, 24-Hour EEGs and EMGs)

Non-Invasive Vascular Diagnostic Studies

Obstetrical Observations

Routine Lab

Routine X-Ray (CT Scan, MRI, MRA, PET Scan, DEXA, HIDA Scans)

Sigmoidoscopy or Colonoscopy

Sleep Studies (Facility only)

SPECT Pulmonary Diagnostic Testing

Primary Care Provider (PCP)/Specialist Notiation to Meridian (in or out of network)

Complex Outpatient Treatment

•Dialysis

•Outpatient Radiation Therapy

Maternity Care/Delivery

Notiication is needed for OB referrals and for OB delivery.

Specialist Oisits/Consults

Meridian Health Plan requests notiication to communicate services with all providers involved, provide additional reporting services and support Case and Disease Management eorts.

PCP/Specialist Notiation is not

Necessary for Claims Payment.

In-network or out-of-network practitioners will be reimbursed for consultations, evaluations and treatments provided within their oes,

when the member is eligible and the service provided is a covered beneit under Michigan

Medicaid and the Medicaid MCO Contract.

Specialty Network Access Form (SNAF)

All referrals for Specialty Care at Hurley Hospital and Michigan State University must follow the SNAF process. Please contact the Meridian Care Management Department directly for referrals

to specialists at these entities. Meridian is required to complete a speciic referral form on

behalf of the PCP.

MeridianRx is the Meridian Pharmacy Beneit Manager. If you have questions about formulary or prior authorizations, please call

866-984-6462.

Corporate Prior Authorization (may require clinical information)

Ambulance Transportation (non-emergent) Anesthesia (when performed with radiology testing) Any Out-of-State Service Request (physician or facility) Bariatric Surgery

Cardiac Catheterization (heart cath)

Cardiac and Pulmonary Rehab

Chemotherapy and Specialty Drugs

• May require review under the medical or pharmacy beneit

DME/Prosthetics and Orthotics > $1000

Elective Inpatient/Surgeries and SNF Admissions

Elective Hospital Outpatient Surgery

(most auto approved at www.mhplan.com)

Hearing Aids

Hereditary Blood Testing (e.g., BRCA for breast and ovarian cancer)

Home Health Care

Hospice and Infusion Therapy

Infusions

Invasive Diagnostic Procedures (hospital setting)

•Hysteroscopy, Arthroscopy, Arteriogram, etc.

•This excludes any procedures listed in the No Prior Authorization

Required section of this document

Specialty Drugs (covered under the medical beneit)

•e.g.Rituxin and Remicade

•View a complete list at www.mhplan.com

Speech, Occupational and Physical Therapy

Weight Management (prior to bariatric surgery)

All emergency inpatient admissions, surgeries and out-of-network 23-hour observations require corporate authorization.

For emergency authorizations, Meridian must be notiied within the irst 24 hours or the following business day.

Out-of-network hospitals must notify Meridian at the time of stabilization and request authorization for all post-stabilization services.

Ultrasounds

Urgent Care

Vision/Glasses

Voiding Cysto-Urethrogram

23-Hour Observation for In-Network Facilities Only (authorization required for elective services)

*All DME supplies and chiropractic services should be provided by an in-network provider.

Outpatient Mental Health Services: No prior authorization is required for the irst 10 visits, but notiication from the Behavioral Health Provider to Meridian is requested for the second 10 visits. The Medicaid beneit is 20

outpatient mental health visits per calendar year. Please contact the Meridian Behavioral Health department for assistance at 888-222-8041.

Non-Covered Bene The following services are not covered beneits under Medicaid and will not be reimbursed by Meridian: Aqua Therapy, Children’s Speech, Physical and Occupational Therapy covered under School Based Services, Community mental health services, Convenience Items, Cosmetic Services, Functional Capacity, Infertility Services and any other service otherwise not covered by Medicaid.