Documents and Forms

Assign Your Care Decisions

Advance Directives

Advance Directives are legal records. They are used when you are very sick and cannot explain the kind of care you want. They let your family, friends and doctors know about your end-of-life choices ahead of time.

This document provides information about advanced directives such as a living will and durable power of attorney for health care.

• Advance Directives Information (PDF)

Appointment of Representative Form (CMS-1696)

An appointed representative is a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

Use this form to appoint a representative to act on your behalf. Once you have completed and signed this form, please mail to the following address:

MeridianComplete
777 Woodward Ave, Suite 700
Detroit, MI 48226

• Appointment of Representative Form 1696 (PDF)

Grievance & Coverage Decisions

Part C

To file a request for a Medicare Part C (medical care) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

• Member Request for Reimbursement (PDF)
  Member Reimbursement Form & Foreign Claim Questionnaire (PDF) - coming soon
  Use this form to request reimbursement for medical services that you paid out of pocket for but believe should have been covered by the plan.
  
  
• Medicare Grievance Form
  Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.

Part D

To file a request for a Medicare Part D (prescription drug) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

• Member Request for Reimbursement (Prescription Medication) (PDF)
  Use this form to request reimbursement for a prescription/medication that you paid out of pocket for but believe should have been covered by the plan.
  
  
• Medicare Grievance Form
  Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.
  
  
• Part D Coverage Determination Request Form (PDF)
  Use this form to ask us to make a coverage determination and/or prior authorization. Once you have completed and signed this form, please mail to the address below.
  
  MeridianComplete
  Attn: Coverage Determination/Appeals
  777 Woodward Ave, Suite 700
  Detroit, MI 48226
  
  
• Part D Redetermination Request Form (PDF)
  If MeridianComplete denied your request for coverage of (or payment for) a prescription drug, use this form to ask us for a redetermination (appeal) of our decision. Once you have completed and signed this form, please mail to the address below.
  
  MeridianComplete
  Attn: Coverage Determination/Appeals
  777 Woodward Ave, Suite 700
  Detroit, MI 48226

Gas Mileage Reimbursement Forms

• The Medical Transportation Statement Form will have 3 new items to be filled out by the transportation provider in section 2. Everything else will remain the same. In order to receive Non-Emergency Medical Transportation gas mileage reimbursement, please complete this form Medical Transportation Statement Form (PDF)

• Family members with road offences can get NEMT payment for members that can consent, but you need to sign and complete NEMT Personal Choice Acknowledgement form (PDF)

Assign Your Care Decisions

Advance Directives

Advance Directives are legal records. They are used when you are very sick and cannot explain the kind of care you want. They let your family, friends and doctors know about your end-of-life choices ahead of time.

This document provides information about advanced directives such as a living will and durable power of attorney for health care.

• Advance Directives Information (PDF)

Appointment of Representative Form (CMS-1696)

An appointed representative is a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

Use this form to appoint a representative to act on your behalf. Once you have completed and signed this form, please mail to the following address:

MeridianComplete
777 Woodward Ave, Suite 700
Detroit, MI 48226

• Appointment of Representative Form 1696 (PDF)

Grievance & Coverage Decisions

Part C

To file a request for a Medicare Part C (medical care) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

• Member Request for Reimbursement (PDF)
  Member Reimbursement Form & Foreign Claim Questionnaire (PDF) - coming soon
  Use this form to request reimbursement for medical services that you paid out of pocket for but believe should have been covered by the plan.
  
  
• Medicare Grievance Form
  Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.

Part D

To file a request for a Medicare Part D (prescription drug) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.

• Member Request for Reimbursement (Prescription Medication) (PDF)
  Use this form to request reimbursement for a prescription/medication that you paid out of pocket for but believe should have been covered by the plan.
  
  
• Medicare Grievance Form
  Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.
  
  
• Part D Coverage Determination Request Form (PDF)
  Use this form to ask us to make a coverage determination and/or prior authorization. Once you have completed and signed this form, please mail to the address below.
  
  MeridianComplete
  Attn: Coverage Determination/Appeals
  777 Woodward Ave, Suite 700
  Detroit, MI 48226
  
  
• Part D Redetermination Request Form (PDF)
  If MeridianComplete denied your request for coverage of (or payment for) a prescription drug, use this form to ask us for a redetermination (appeal) of our decision. Once you have completed and signed this form, please mail to the address below.
  
  MeridianComplete
  Attn: Coverage Determination/Appeals
  777 Woodward Ave, Suite 700
  Detroit, MI 48226

Gas Mileage Reimbursement Forms

• The Medical Transportation Statement Form will have 3 new items to be filled out by the transportation provider in section 2. Everything else will remain the same. In order to receive Non-Emergency Medical Transportation gas mileage reimbursement, please complete this form Medical Transportation Statement Form (PDF)

• Family members with road offences can get NEMT payment for members that can consent, but you need to sign and complete NEMT Personal Choice Acknowledgement form (PDF)

Michigan Department of Health & Human Services (MDHHS) Consent to Share Behavioral Health Information Form

When you receive health care, your health care provider and health plan keep records about your health and the services you receive. This information becomes part of your medical record. This form can be used to give or take away consent to share information about your Behavioral Health services and/or substance use disorder.

The Consent to Share Behavioral Health Information form can be found at https://www.michigan.gov/mdhhs/keep-mi-healthy/mentalhealth/behavioral/consent/michigan-behavioral-health-standard-consent-form