Documents and Forms
Medical Referrals & Authorizations
- 2022 Inpatient Prior Authorization Fax Submission Form (PDF)
- 2022 Outpatient Prior Authorization Fax Submission Form (PDF)
- Authorization Referral
- 2020 MeridianComplete Authorization Lookup (PDF)
- Behavioral Health Discharge Transition of Care Form (PDF)
- Weight Watchers® Form (PDF)
Quality Improvement
- 2022 MI HealthLink Annual Evaluation Overview (PDF) - coming soon
- 2023 MI HealthLink Annual Evaluation Overview (PDF) - coming soon
Pharmacy
Preventive Care (HEDIS®)
- Breast Cancer Screening Exclusion Form (PDF)
- Colorectal Cancer Screening Exclusion Form (PDF)
- Diabetes Exclusion Form (PDF)
- Diabetes Attestation Forms (PDF)
- Care for Older Adults Attestation Form (PDF)
- HEDIS® Quick Reference Guide 2023 (PDF)
Adverse Events
Billing
- Timely Submission of Encounter Data by Medicare-Medicaid Plans (MMPs) to CMS (PDF)
- Prohibition Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program (PDF)
- Request for Provider Dispute Form