Utilization Management

The objective of MeridianComplete's Utilization Management program is to ensure that medical services provided to members are medically necessary and/or appropriate and a covered benefit of MeridianComplete.

How to Submit Prior Authorizations

MeridianComplete has three easy ways for you to submit prior authorizations. All providers will be required to send MeridianComplete Prior Authorization requests in accordance with processes defined below*: 

1. Electronically: MeridianComplete's Provider Authorization Form
2. Fax: Refer to Utilization Management's fax numbers. Please include pertinent clinical documentation with the request if indicated. The fax cover sheet is available on our website.
   • Please send any inpatient admissions, Skilled Nursing Facility, Inpatient Rehab, and Long-Term Acute Care Facility requests to the new inpatient fax number:  1-313-294-5470 
   • Please send any outpatient authorization requests to:  1-313-394-1535
3. Phone: Call MeridianComplete at 1-855-323-4578. You will be prompted to select additional options in the phone tree indicating whether your authorization call is regarding inpatient or outpatient services.

Note: There will be significant enhancements to the Provider Portal for submitting authorizations. To accommodate the upgrade, the prior authorization submission features for MeridianComplete has been temporarily disabled since June 1, 2017. We will notify you via fax blast when the portal functionality is available.

*Urgent request:  A request for medical care or services where application of the time frame for making routine or non-life threatening care determinations:          

• Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state, or
• In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.

Prior Authorization and Referral Guidelines

Emergent Inpatient and Post-Acute Care

Our nurse reviewers are assigned to follow members to promote collaboration with the facility's review staff and management of the member across the continuum of care. Our nurse reviewers assess the care and services provided in an inpatient setting and the member's response to the care by applying InterQual® criteria for inpatient and post-acute care. Our nurse reviewers apply MeridianComplete's observation policy for emergent unplanned observation stays. Together with the facility's staff, Utilization Management's clinical staff coordinates the member's discharge needs.

All elective hospital admissions initiated by the PCP or specialist requires Corporate Pre-Service review.

Denials

All denial determinations are rendered by physicians. A nurse reviewer contacts the provider telephonically to inform them of the denial decision, and reason for the denial. Written denial notification is sent via fax to the provider and mailed to the member. The written denial notification will include the reason for the denial, the reference to the benefit provision and/or clinical guideline on which the denial decision was based, and directions on how to obtain a copy of the reference. You may contact the Utilization Management Department any time at 1-855-323-4578 to request a copy of MeridianComplete's medical necessity guidelines.

For questions on Expedited Appeals and Non-Urgent Pre Service Appeals, please visit the Grievance and Appeals page.

Members can appeal a medical decision within 60 calendar days of receiving our letter denying the initial request for services or payment on their own behalf. They can also designate a representative, including a relative, friend, advocate, doctor or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member's behalf. This statement must be sent to MeridianComplete at:

MeridianComplete
Attn: Appeals & Grievances, Medicare Operations
7700 Forsyth Blvd
St. Louis, MO 63105

Fax: 1-844-273-2671

Members should call MeridianComplete at 1-855-323-4578 (TTY: 711), Monday - Sunday from 8 a.m. – 8 p.m. to learn how to name an authorized representative.

Care Coordination

Our Care Coordinators may contact you for other reasons:

• To coordinate a plan of care
• To confirm a diagnosis
• To verify appropriate follow-up such as cholesterol/LDL-C screening or HbA1c testing
• To identify compliance issues
• To discuss other problems and issues that may affect outcomes of care
• To inform you of a member's potential need for behavioral health follow-up

The objective of MeridianComplete's Utilization Management program is to ensure that medical services provided to members are medically necessary and/or appropriate and a covered benefit of MeridianComplete.

How to Submit Prior Authorizations

MeridianComplete has three easy ways for you to submit prior authorizations. All providers will be required to send MeridianComplete Prior Authorization requests in accordance with processes defined below*: 

1. Electronically: MeridianComplete's Provider Authorization Form
2. Fax: Refer to Utilization Management's fax numbers. Please include pertinent clinical documentation with the request if indicated. The fax cover sheet is available on our website.
   • Please send any inpatient admissions, Skilled Nursing Facility, Inpatient Rehab, and Long-Term Acute Care Facility requests to the new inpatient fax number: 1-844-930-4389
   • Please send any outpatient authorization requests to: 1-855-323-4578
   • Please send any inpatient behavioral health authorization requests to: 1-844-930-4389
   • Please send any outpatient behavioral health authorization requests to: 1-1-855-323-4578
3. Phone: Call MeridianComplete at 1-855-323-4578. You will be prompted to select additional options in the phone tree indicating whether your authorization call is regarding inpatient or outpatient services.

*Urgent request:  A request for medical care or services where application of the time frame for making routine or non-life threatening care determinations:          

• Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state, or
• In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.

Prior Authorization and Referral Guidelines

Emergent Inpatient and Post-Acute Care

Our nurse reviewers are assigned to follow members to promote collaboration with the facility's review staff and management of the member across the continuum of care. Our nurse reviewers assess the care and services provided in an inpatient setting and the member's response to the care by applying InterQual® criteria for inpatient and post-acute care. Our nurse reviewers apply MeridianComplete's observation policy for emergent unplanned observation stays. Together with the facility's staff, Utilization Management's clinical staff coordinates the member's discharge needs.

All elective hospital admissions initiated by the PCP or specialist requires Corporate Pre-Service review.

Denials

All denial determinations are rendered by physicians. A nurse reviewer contacts the provider telephonically to inform them of the denial decision, and reason for the denial. Written denial notification is sent via fax to the provider and mailed to the member. The written denial notification will include the reason for the denial, the reference to the benefit provision and/or clinical guideline on which the denial decision was based, and directions on how to obtain a copy of the reference. You may contact the Utilization Management Department any time at 1-855-323-4578 to request a copy of MeridianComplete's medical necessity guidelines.

For questions on Expedited Appeals and Non-Urgent Pre Service Appeals, please visit the Grievance and Appeals page.

Members can appeal a medical decision within 60 calendar days of receiving our letter denying the initial request for services or payment on their own behalf. They can also designate a representative, including a relative, friend, advocate, doctor or other person, to act for them. The member and the representative must sign and date a statement giving the representative legal permission to act on the member's behalf. This statement must be sent to MeridianComplete at:

MeridianComplete
Attn: Medicare Appeals
P.O. Box 44260
Detroit, MI 48244

Fax: 313-463-5259

Members should call MeridianComplete at 1-855-323-4578 (TTY: 711), Monday - Sunday from 8 a.m. – 8 p.m. to learn how to name an authorized representative.

Care Coordination

Our Care Coordinators may contact you for other reasons:

• To coordinate a plan of care
• To confirm a diagnosis
• To verify appropriate follow-up such as cholesterol/LDL-C screening or HbA1c testing
• To identify compliance issues
• To discuss other problems and issues that may affect outcomes of care
• To inform you of a member's potential need for behavioral health follow-up