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Understanding Prior Authorization

Helping you get the right care at the right time

Prior authorization helps ensure the services provided to you are medically necessary and follow plan benefits. Meridian reviewers consider standards of practice and your overall medical condition. Denials are made by a medical director.

Note that services performed by out-of-network providers, except emergency services, require authorization.

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Prior Authorization: What you need to know

Some healthcare services, tests, procedures, or medications need approval from Meridian before your provider can give them to you. This approval is called prior authorization.

Prior authorization helps make sure:

  • The care you get is medically necessary
  • You receive the right care at the right time
  • Services follow Illinois Medicaid rules and your plan benefits

No, you do not need to submit any paperwork yourself.

Your doctor or other healthcare provider is responsible for requesting prior authorization from Meridian when it is needed. You do not need to submit any paperwork.

You do not need a referral from your primary care provider (PCP) to see a specialist. However, some specialist services may still require prior authorization. Your provider has a list of care that needs prior authorization.

If you need a care service that requires prior authorization, your provider needs to fill out a Prior Authorization Request Form and send it to us.

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Some services need prior authorization before they can be covered. Examples include, but are not limited to, the following:

  • Inpatient hospital stays
  • Certain outpatient hospital services
  • Some surgeries and procedures
  • High cost imaging (like MRIs or CT scans)
  • Home health care services
  • Hospice care
  • Certain medical equipment and supplies
  • Some therapy services (physical, occupational, speech)
  • Some prescription medications

Not all services need prior authorization, and emergency care never requires prior authorization.

For a full list of medical services covered by the plan, see the Meridian Medicaid Member Handbook.

Meridian does not require prior authorization for the following services (prior authorization may be required for out-of-network providers):

  • Crisis stabilization care (outpatient mental health services for no less than 30 days post-crisis)*
  • Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services
  • Emergency services, including emergency medical screening
  • Family planning and reproductive health services
  • Local health department services
  • Pediatric Palliative Care Program (PPCP) services
  • Preventive prenatal, perinatal, and postpartum services
  • School dental programs
  • School-based health centers

*Notification requirements may apply. See Behavioral Health for more details.

For a full list of medical services covered by the plan, see the Meridian Member Handbook.

We are here to support you and your well-being. This includes the emotions and behaviors that affect your overall health or your behavioral health. For more details on your benefits, see Behavioral Health.

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Our goal is to provide the right drug coverage for our members. We work closely with doctors and pharmacists to make sure we offer medications that treat a range of conditions and illnesses.

The Preferred Drug List is the list of drugs covered by Meridian. This list includes prescriptions and over-the-counter drugs used for treatment. Most are covered without a referral or medical review.

Other drugs require prior authorization from your doctor. If needed, your provider will fill out a prior authorization request form for you.

Note: Sometimes a drug on the PDL may not work for you or makes you sick. Your provider can ask for a different drug via the prior authorization request form.

Visit Pharmacy Services for more information.

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Once Meridian receives the prior authorization request:

  • Clinical experts review the request using medical guidelines
  • A decision is made based on medical necessity and your plan benefits
  • You and your provider are notified of the decision within established timeframes

If more information is needed, Meridian may ask your provider for additional details.

Meridian follows Illinois Medicaid and state requirements for reviewing prior authorization requests. Decision timeframes depend on:

  • The type of service requested
  • Whether the request is urgent

For standard requests, we will make a decision and notify you and your PCP, as well as any other providers involved in writing within 5 calendar days of receiving all required information. Your provider can tell Meridian if a request is urgent. Then a decision will be made within 48 hours after receiving all required information.

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If your prior authorization request is denied:

  • You will receive an Adverse Benefit Determination letter explaining the decision
  • The letter will explain your appeal rights
  • You can ask your provider to help you file an appeal if you disagree with the decision

Visit Appeals and Grievances for more details.

Within thirty (30) calendar days after the date on the Meridian appeal Decision Notice, you may choose to ask for a review by someone outside of Meridian. This is called an external review.

The outside reviewer must meet the following requirements:

  • Be a board-certified provider with the same or like specialty as your treating provider
  • Currently practicing
  • Have no financial interest in the decision
  • Not know you and will not know your identity during the review

External review is not available for appeals related to services received through the Elderly Waiver; Persons with Disabilities Waiver; Traumatic Brain Injury Waiver; HIV/Aids Waiver; or the Home Services Program.

Your letter must ask for an external review of that action and should be sent to:

Meridian Appeals Dept.
PO Box 716
Elk Grove Village, IL 60009

Have questions? Call Member Services

Meridian Member Services can help you:

  • Understand if a service needs prior authorization
  • Answer questions about coverage
  • Explain letters you receive about your care