Utilization Management
The objective of the Meridian Medicare-Medicaid Plan (MMP) Utilization Management (UM) program is to ensure that medical services provided to members are medically necessary and/or appropriate, and that they conform to plan benefits.
How to Submit Referrals
There are three easy ways for you to submit referrals*
- Electronically (Preferred Method): Meridian's Provider Authorization page or secure online portal: Provider.ILMeridian.com.
- Fax: Refer to Utilization Management's fax numbers. Please include pertinent clinical documentation with the request if indicated.
- Phone: Urgent requests must be submitted by phone. Ensure the request is identified as "urgent" to expedite the pre-service review process.
*Urgent request: A request for medical care or services when the application 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 provider 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.
Referral Types
The table below lists requirements for the most requested services but is not all-inclusive. For some cases, requested services may require pre-service authorization. For questions, please contact the Utilization Management regional team for your coverage area.
Copies of the criteria utilized in decision-making are available upon request by calling the UM department at 1-855-580-1689 (TTY: 711), Monday - Friday from 8:00 a.m. - 8:00 p.m.
| No Prior Authorization | PCP Notification to Meridian MMP | Corporate Prior-Authorization (Pre-service review) |
|---|---|---|
| NO REFERRAL REQUIRED | REFERRAL NOTIFICATION ONLY | CLINICAL INFORMATION |
|
PCP notification is not necessary for claims payment. In-network or out-of-network practitioners will be reimbursed for consultations, evaluations and treatments provided within their offices, when the member is eligible and the service provided is a covered benefit. |
*All emergency inpatient admissions, surgeries and 23-hour observations require corporate authorization from Meridian Complete. For emergency authorizations, Meridian MMPmust be notified within the first 24 hours or the following business day. |
| * All DME supplies and services should be provided by an in-network provider | ||
Corporate Pre-Service Review
Meridian MMP must review and approve select services before they are provided. Clinical reviews are conducted to determine if a service is clinically appropriate, performed in the appropriate setting, and is a benefit. Clinical information is necessary for all services that require medical necessity clinical review.
UM clinical staff uses plan documents for benefit determination and medical necessity coverage guidelines to support decisions. All review decisions to deny coverage are made by our medical directors. In certain circumstances, an external review of service requests are conducted by qualified, licensed physicians with the appropriate clinical expertise.
Meridian MMP’s medical necessity guidelines are based on current literature review, consultation with practicing physicians and medical experts, government agency policies, and standards adopted by national accreditation organizations. It is the responsibility of the attending physician to make clinical decisions about medical treatment. Decisions should be consistent with accepted principles of professional medical practice and in consultation with the member.
To ensure timely decisions, clinical information is required for all clinical review requests. A decision time frame is based on the date supporting clinical information is received.
- Ensure all supporting clinical information is included with the initial request
- Submission via fax to your regional team is preferred
- If clinical information is not received, our UM staff will fax a request for information and/or contact the physician or specialist verbally to collect documentation
Clinical information should be provided at least 14 days before a service. The facility is responsible for ensuring authorization.
Clinical information includes a member's:
- History of presenting problem
- Physical assessment
- Diagnostic results
- Photographs
- Consultations
- Previous and current treatment
- Member's response to treatment
Meridian MMP provides a reference number for all referrals.
| REFERRAL | MAKES DECISION | FAX/PHONE NOTIFICATION | WRITTEN NOTIFICATION (DENIALS) |
|---|---|---|---|
| Non-urgent pre-service review | Within 14 days of receipt of the request. | Within 14 days of receipt of the request. | Within 14 days of receipt of the request. |
| Urgent pre-service review | Within 72 hours of receipt of the request. | Within 72 hours of the request. | Within 72 hours of the request. |
| Urgent concurrent | Within 24 hours of receipt of the request. 72 hours if clinical is not included. | Within 24 hours of receipt of the request. 72 hours if clinical not included. | Within 72 hours of the decision. |
Inpatient Review
Nurse reviewers are assigned to follow members at specific acute care facilities to collaborate with the facility's staff and for care management. Our nurse reviewers assess the care and services given in inpatient settings and the member's response by applying InterQual® criteria and Meridian MMP’s observation policy. Together with the facility's staff, UM's clinical staff coordinates a member's discharge.
All elective hospital admissions initiated by a PCP or specialist require corporate pre-service review. You may call 1-855-580-1689 to enter the authorization request in our managed care system, or fax requests to us. Please include documentation of medical necessity for the quickest turnaround time. The facility is responsible for ensuring authorization.
Denial
All denial determinations are rendered by physicians. A nurse reviewer contacts the provider telephonically to inform them of the denial decision and reason. Contact information to discuss the denial with Meridian MMP’s medical director is included.
Written denial notification is faxed and mailed to the member. Treating physicians who want to discuss a utilization review determination with the decision-making medical director may contact the UM department at 1-855-580-1689.
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 for obtaining a copy of the reference. You may contact the Utilization Management department by calling 1-855-580-1689.
For questions on expedited appeals and non-urgent pre-service appeals, please visit the Grievance and Appeals page.
Care Coordination
Our Care Coordinators may contact you to:
- coordinate a plan of care
- confirm a diagnosis
- verify appropriate follow-up such as cholesterol/LDL-C screening or HbA1c testing
- identify compliance issues
- discuss other problems and issues that may affect outcomes of care
- inform you of a member's potential need for behavioral health follow-up
You may refer a member for care coordination via our secure portal Provider.ILMeridian.com, MCS "Notify CM" or by calling the UM department at 1-855-580-1689.