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.

Prior Authorization Rules for MeridianComplete (PDF)

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 Prior-Authorization (Pre-service review)
NO REFERRAL REQUIRED	REFERRAL NOTIFICATION ONLY	CLINICAL INFORMATION
Life-Threatening Emergencies - ER Screening Urgent Care Routine Lab Routine X-Ray including CT Scan, MRI, MRA, PET Scan DEXA, HIDA Scans Sleep Studies Obstetrical Observations Gastroenterology Diagnostics Ultrasounds Annual Vision / Glasses Audiology Services and Testing (excluding hearing aids) Chiropractic Services (18 Visits per Year) Annual Mammogram and Pap Colposcopy after an Abnormal Pap Myoview Stress Test Cardiac Stress Test Neurology and Neuromuscular Diagnostic Testing, including EEGs, 24 Hour EEG's and EMGs Bronchoscopy DME / Prosthetics and Orthotics = $1000 (*In network only) EKG, Echocardiography Sigmoidoscopy or Colonoscopy Cardiograph Allergy Testing Bone Densitometry Studies Barium Enema Non-Invasive Vascular Diagnostic Studies IVP, Intravenous Pyelography SPECT Pulmonary Diagnostic Testing Voiding Cysto-Urethrogram	*Specialist Office Services	Elective Inpatient Admissions/Surgeries/SNF admissions Elective Hospital Outpatient Surgery Elective Facility-Based Diagnostic Services DME / Prosthetics and Orthotics > $1000 (In Network Only) Home Health Care/Hospice/Infusion Therapy Services Speech, Occupational and Physical Therapy Weight Management (prior to Bariatric Surgery) Bariatric Surgery Heredity blood testing, e.g., BRCA for Breast and Ovarian Cancer Any service request to an Out-of-State physician or facility Hearing Aids All Emergency Inpatient Admissions, Surgeries and 23-Hour Observations require corporate authorization from Meridian Complete. For emergency authorizations, MeridianComplete must be notified within the first 24 hours or the following business day.
	Complex Outpatient Treatment Dialysis Outpatient Radiation Therapy Chemotherapy
	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.