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

• Member Request for Reimbursement (PDF)

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

• Understanding Adverse Events (PDF)
• Adverse Events Reporting Form (PDF)

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

Grievance & Coverage Decisions

• Part D Coverage Determination Request Form (PDF)
• Part D Redetermination Request Form (PDF)

Regulatory Requirements Manual

• Michigan Regulatory Requirements Manual (PDF)

Critical Incidents

• Critical Incident Form (PDF)
• MI Reporting Grid (PDF)

Prior Authorization Rules

• Prior Authorization Rules (PDF)

Hospice Information

• Hospice Information for Medicare Part D plans (PDF)

MeridianComplete Pay for Performance Program

• MeridianComplete Pay for Performance Program (PDF)

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

• 2021 MeridianComplete Annual Evaluation Overview (PDF)
• 2021 Michigan Complete Health Annual Evaluation Overview (PDF)
• 2022 MI HealthLink Annual Evaluation Overview (PDF) - coming soon
• 2023 MI HealthLink Annual Evaluation Overview (PDF) - coming soon

Pharmacy

• Member Request for Reimbursement (PDF)

Preventive Care (HEDIS®)

• Breast Cancer Screening Exclusion Form (PDF)
• Colorectal Cancer Screening Exclusion Form (PDF)
• Diabetes Exclusion Form (PDF)
• HEDIS® Quick Reference Guide 2023 (PDF)

Adverse Events

• Understanding Adverse Events (PDF)
• Adverse Events Reporting Form (PDF)

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

Grievance & Coverage Decisions

• Part D Coverage Determination Request Form (PDF)
• Part D Redetermination Request Form (PDF)

Regulatory Requirements Manual

• Michigan Regulatory Requirements Manual (PDF)

Critical Incidents

• Critical Incident Form (PDF)
• MI Reporting Grid (PDF)

Prior Authorization Rules

• Prior Authorization Rules (PDF)

Hospice Information

• Hospice Information for Medicare Part D plans (PDF)

MeridianComplete Pay for Performance Program

• MMP Pay 4 Performance Flyer (PDF)

Provider Change Request

• PCP Change Request (PDF)