Utilization Management
The objective of Meridian's Utilization Management program is to ensure that medical services provided to members are medically necessary and/or appropriate, as well as in conformance with the benefits of the plan.
How to Submit Referrals
Meridian has three easy ways for you to submit referrals*
- Electronically: Meridian's Provider Authorization page or secure online Provider Portal.
- Fax: Refer to Utilization Management's fax numbers. Please include pertinent clinical documentation with the request if indicated.
- Phone: Urgent requests must always be submitted by calling your regional team. Make sure you identify the request as "urgent" to expedite the pre-service review process.
*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.
Types of Referrals
The table below provides our referral requirements for the most commonly requested services. This list is not all inclusive. In rare cases, requested services may require pre-service authorization. If you have questions, 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 Utilization Management department at 1-888-322-8843 (TTY: 711), Monday - Sunday from 8 a.m. - 8 p.m.
Please refer to this PDF document for a detailed list of services that require prior authorization and/or referral.
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.
No Prior Authorization | PCP Notification to MeridianComplete | Corporate |
|---|---|---|
NO REFERRAL REQUIRED | REFERRAL NOTIFICATION ONLY | CLINICAL INFORMATION |
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*All Emergency Inpatient Admissions, Surgeries and 23-Hour Observations require corporate authorization from Meridian Complete. For emergency authorizations, MeridianCompletemust be notified within the first 24 hours or the following business day. |
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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 DME Supplies and Services should be provided by an in-network provider | ||
All Outpatient Mental Health Services must be authorized by calling 888-222-8041. | ||
Corporate Pre-Service Review
MeridianComplete must review and approve select services before they are provided. The primary reasons for clinical review are to determine whether the service is clinically appropriate, is performed in the appropriate setting and is a benefit. Clinical information is necessary for all services that require clinical review for medical necessity.
Utilization Management clinical staff uses plan documents for benefit determination and Medical Necessity Coverage Guidelines to support Utilization Management decision-making. All Utilization 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.
MeridianComplete's Medical Necessity Guidelines are based on current literature review, consultation with practicing physicians and medical experts in their particular field, government agency policies, and standards adopted by national accreditation organizations. It is the responsibility of the attending physician to make all clinical decisions regarding medical treatment. These decisions should be made consistent with generally accepted principles of professional medical practice and in consultation with the member.
Clinical information is required for all clinical review requests to ensure timely decisions by MeridianComplete. The decision time frame is based on the date we receive the supporting clinical information. To ensure a timely decision, make sure all supporting clinical information is included with the initial request. The preferred method of clinical review submission is via fax to your regional team. If clinical information is not received with the request our Utilization Management staff will send a fax request for the information and/or contact the physician or specialist verbally to collect the necessary documentation.
Clinical information includes relevant information regarding the member's:
- History of presenting problem
- Physical assessment
- Diagnostic results
- Photographs
- Consultations
- Previous and current treatment
- Member's response to treatment
Clinical information should be provided at least 14 days prior to the service. The facility is responsible for ensuring authorization.
MeridianComplete provides a reference number on 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. 48 hours if clinical is not included. | Within 24 hours of receipt of the request. 48 hours if clinical not included. | Within 72 hours of the decision. |
Inpatient Review
Our nurse reviewers are assigned to follow members at specific acute care facilities 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 inpatient setting and the member's response to the care by applying InterQual® criteria and
MeridianComplete's Observation policy. 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. You may call 1-888-322-8843, to enter the authorization request in our Managed Care System, or fax requests to us. Be sure to include documentation of medical necessity to facilitate the earliest possible turnaround time. The facility is responsible for ensuring authorization.
MeridianComplete provides a reference number on all referrals.
Denial
All denial determinations are rendered by physicians. A nurse reviewer contacts the provider telephonically to inform them of the denial decision, reason for the denial and contact information to discuss the denial with
MeridianComplete's medical director. Written denial notification is sent via fax and mailed to the member. Treating physicians who would like to discuss a utilization review determination with the decision-making medical director may contact the Utilization Management Department at 1-888-322-8843.
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 1-888-322-8843 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.
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
You may refer a member for care coordination via MCS "Notify CM" or calling the Utilization Management Department at 1-888-322-8843.