Authorization
Overview
MEDICAID PRIOR AUTHORIZATION PROCEDURES OVERVIEW
You may forward your request to Meridian via fax: 313-463-5254 or contact Meridian by Phone: 888-322-8844.
Most outpatient services are auto approved via the secure Meridian Provider Portal at www.mhplan.com/mi/mcs.
No Prior Authorization
Allergy Testing
Audiology Services and Testing (excluding hearing aids)
Barium Enema
Bone Densitometry Studies
Brain Surgery*
Bronchoscopy
Cardiac Procedures*
Cardiac Stress Test
Cardiograph
Chemotherapy/Infusions*
Chiropractic Services (in-network only
†
)
Cleft Lip Repair*
Colposcopy after an Abnormal Pap
DME/Prosthetics and Orthotics ≤ $1000 (in-network only
†
)
Electrocardiography
Endoscopy
Gastroenterology Diagnostics
GI Procedures*
Hernia Repair*
Intravenous Pyelography (IVP)
Life-Threatening Emergencies (ER Screening)
Lymph Node Surgery*
Mammogram and Pap Test
Myoview Stress Test
Nerve/Tendon Surgery*
Neurology and Neuromuscular Diagnostic Testing
(EEGs, 24-Hour EEGs and EMGs)
Non-Invasive Vascular Diagnostic Studies
Obstetrical Observations
Orbital Procedure*
Orthopedic Replacement/Revision*
Physical, Occupational, and Speech Therapy
(evaluations only)
Pulmonary/Vascular Procedures*
Routine Lab
Routine X-Ray (CT Scan, MRI, MRA, PET Scan, DEXA,
HIDA Scans)
Sigmoidoscopy or Colonoscopy
Skin Graft*
Sleep Studies (Facility only)
SPECT Pulmonary Diagnostic Testing
Spleen/Liver Procedure*
Ultrasounds
Urgent Care
Video EEG*
Vision/Glasses
Voiding Cysto-Urethrogram
23-Hour Observation for In-Network Facilities Only
(authorization required for elective services)
Complex Outpatient Treatment
• Dialysis
• Outpatient Radiation Therapy
Maternity Care/Delivery
Notification is needed for OB referrals and for OB
delivery.
Specialist Office Visits/Consults
Meridian Health Plan requests notification to
communicate services with all providers
involved, provide additional reporting services and
support Case and Disease Management efforts.
PCP/Specialist Notification is not Necessary
for Claims Payment.
In-network or out-of-network practitioners will
be reimbursed for consultations, evaluations and
treatments provided within their offices, when the
member is eligible and the service provided is a
covered benefit 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 specific referral form on behalf of
the PCP.
Primary Care Provider (PCP)/Specialist
Notification to Meridian (in or out of network)
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 benefit
DME/Prosthetics and Orthotics > $1000 (faxed requests only)
Elective Inpatient/Surgeries and SNF Admissions
Elective Hospital Outpatient Surgery
• Excludes those listed under No Prior Authorization
• Most auto approved at www.mhplan.com
Genetic Testing
Hearing Aids
Hereditary Blood Testing
(e.g., BRCA for breast and ovarian cancer)
Home Health Care
Hospice and Infusion Therapy
Infusions
Specialty Drugs (covered under the medical benefit)
• 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 notified within the first 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.
Non-Covered Benefits: The following services are not covered benefits 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.
Outpatient Mental Health Services: No prior authorization is required for the first 3 visits, but notification using
the Continued Outpatient Treatment Notification Form (COTNF) from the Behavioral Health Provider to Meridian is
requested for the remaining 17 visits. The COTNF form is located at www.mhplan.com. The Medicaid benefit is 20
outpatient mental health visits per calendar year. Please contact the Meridian Behavioral Health department for
assistance at 888-222-8041.
Note: Prior Authorization Procedures refer to Medicaid covered services ONLY.
MeridianRx is the Meridian Pharmacy Benefit
Manager. If you have questions about formulary or
prior authorizations, please call 866-984-6462.
*These outpatient surgeries do not require authorization when performed at in-network facility. OON facilities require
prior authorizations.
†
All DME supplies and chiropractic services should be provided by an in-network provider.