Prior Authorization Supplemental Form

Date: 12/23/24

Meridian and its family of plans has a new Prior Authorization (PA) supplemental form for authorization requests with more than four procedure codes. Find it on our Prior Authorization web page.

What is the PA supplemental form? An optional page meant to be used in conjunction with the plans’ Prior Authorization request form when a request exceeds more than four (4) procedure codes. This form should never be submitted alone.

Use the supplemental form when requesting more than four (4) procedure codes.

Is it required? No, the PA supplemental form is optional. If a request doesn’t exceed four (4) procedure codes, this form is not required.

The PA supplemental form is located on our Prior Authorization web page.