Prior Authorization/Referral

Some covered services or medications may need approval from Meridian, and this is called a Prior Authorization (PA). You do not need a paper referral from Meridian to see a provider but your provider may need to request a prior authorization from Meridian for a service to be approved.

The recently passed Prior Authorization Reform Act is helping us make our services even better. This bill took effect January 1, 2022.

Our prior authorization process will see many improvements. We will be more clear with processes. And we will reduce wait times for things like tests or surgeries. You will also see improved fairness with our PA process.

Our current PA process is NCQA certified. It meets many of the new law's standards. However, we see this as a time to continue improving our services.

For clinical criteria, please see the information linked below. To request PA information or receive additional support, please contact us at 866-606-3700 (TTY: 711).

Below is a list of services that require prior authorization from Meridian before your healthcare provider can proceed with treatment. 

Ambulatory Surgery Center Some services require prior authorization
Bariatric Surgery (Certain restrictions and limitations may apply) Yes
Birthing Centers Yes
Durable Medical Equipment (DM) Some items require prior authorization
High Cost Radiology Yes
Home Health Care Services Yes
Hospice Care Yes
Hospital Services Inpatient Yes
Hospital Services Outpatient Some services require prior authorization
Laboratory Services (HPP):  All services necessary for the diagnosis, treatment and prevention of disease, and for the maintenance of health. Some services require prior authorization
Maternity Services (HPP) Some services require prior authorization
Medical Services Clinic Yes
Orthotics & Prosthetics (O&P):  Braces (non-dental) and other mechanical or molded devices to support or correct any defect of form or function of the human body. Yes
Oxygen & Respiratory Services (HPP) Some services require prior authorization
Pain Managment Some services require prior authorization
Substance Use Disorder Services (HPP_ Some services require prior authorization
Therapy (OT,PT,ST) Services (Outpatient) Yes
Transplant Services Yes

All such services determined by Illinois Medicaid to be medically necessary shall constitute a Meridian Covered Service.  See the Meridian Member Handbook for more information on coverage out-of-network and out of the Illinois Meridian service area.

Do I need a referral to see a specialist?

No, you do not need a referral from your PCP to see a specialist. You do not need a referral for routine vision care, chiropractic services, or mental health/counseling services.