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 - English (PDF)
  
  
• Directivas Anticipadas de Salud - Spanish (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:

Meridian
PO Box 3060
Farmington, MO 63640-3822

• Appointment of Representative Form 1696

Grievance & Coverage Decisions

Part C

To file a request for a Medicare Part C (medical care) coverage decision or appeal please call Meridian Member Services at 1-855-580-1689 (TTY 711), Monday - Friday from 8 a.m. to 8 p.m. 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)

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 Meridian Member Services at 1-855-580-1689 (TTY 711), Monday - Friday from 8 a.m. to 8 p.m. 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)

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
  

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.

Meridian Medicare-Medicaid Plan (MMP)
Attn: Claims PO Box 4020
Farmington, MO 63640-4022

• Part D Redetermination Request Form
  

If Meridian 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.

Meridian
Attn: Coverage Determination/Appeals
PO Box 3060
Farmington, MO 63640-3822

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 - English (PDF)
  
  
• Directivas Anticipadas de Salud - Spanish (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:

Meridian
PO Box 3060
Farmington, MO 63640-3822

• Appointment of Representative Form 1696

Grievance & Coverage Decisions

Part C

To file a request for a Medicare Part C (medical care) coverage decision or appeal please call Meridian Member Services at 1-855-580-1689 (TTY 711), Monday - Friday from 8 a.m. to 8 p.m. 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)
  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 Meridian Member Services at 1-855-580-1689 (TTY 711), Monday - Friday from 8 a.m. to 8 p.m. 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)
  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
  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.
  
  

  Meridian Medicare-Medicaid Plan (MMP)
  Attn: Claims PO Box 4020
  Farmington, MO 63640-4022

  
  
• Part D Redetermination Request Form
  If Meridian 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.
  
  Meridian
  Attn: Coverage Determination/Appeals
  PO Box 3060
  Farmington, MO 63640-3822