Prior authorization (PA) or precertification is a pre-service review of medical information before the delivery of healthcare services. The purpose is to determine if the care and setting are medically appropriate according to established guidelines, and to engage Meridian’s Care Coordination team.

Each PA is evaluated against evidence-based clinical guidelines to determine medical necessity. See the Clinical Review Guidelines section for details.

• Search code-specific criteria using the Meridian Medicaid Prior Auth Check Tool
• Consult the tools below for members enrolled in our family of plans:
  
  • Ambetter Prior Auth Check Tool
  • Wellcare Meridian Dual Align (HMO D-SNP) Prior Auth Check Tool
  • Wellcare Prior Auth Check Tool
  • YouthCare Prior Auth Check Tool

Step 1: Determine if a PA is required using the Medicaid Prior Auth Check Tool

• Answer a few questions, and the tool will indicate if PA is required

Step 2: Submit the PA request

• Submit PAs through Meridian’s provider portals
• Submit PAs through Meridian’s vendor solutions as noted below. (Clinical review guidelines can be accessed from the vendors’ websites.)
  

  Vendor Solution	Vendor Link
  Dental	Envolve Dental
  MRA, MRI, PET, CT, and Cardiac Imaging	Evolent
  Pain Management	Evolent
  Speech, Occupational and Physical Therapy	Evolent
  Musculoskeletal Services	Evolent
  Oncology/Supportive Drugs for Members Age 18 and Older	Evolent Specialty Services
  Pharmacy	covermymeds
  Non-Emergent Non-Ambulance Transportation	MTM

• Meridian fax submission options
  If submitting a PA request to Meridian by fax, please use the following forms:
  
  • Inpatient Medicaid Prior Authorization Form (PDF)
  • Outpatient Medicaid Prior Authorization Form (PDF)
    
    • Outpatient Authorization Supplemental Form (PDF) – For use when an authorization request exceeds four (4) procedure codes

Meridian does not require pre-service review for the following services (pre-service review 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 Notification Requirements below.

• Inpatient behavioral healthcare: Providers should notify Meridian within 48 hours of admission. If notification requirements are met, utilization review will not be initiated for the first 72 hours of admission.
• Substance use residential treatment: Providers should notify Meridian within 24 hours of initiation of services. Utilization review may begin after the 24-hour notification period.
• Outpatient behavioral healthcare (including partial hospitalization and intensive outpatient treatment): Providers should notify Meridian within 24 hours of initiation of services. Utilization review may begin after the 24-hour notification period.

• Planned (elective) inpatient hospital admissions must have PA before the admission occurs.
• Unplanned inpatient hospital admissions require notification to Meridian within 48 hours of admission to the facility. If notification requirements are met, utilization review will not be initiated for the first 72 hours of admission.
• Skilled nursing, long-term acute care, and rehabilitation facility admissions require PA before the admission occurs.

Medications on the Preferred Drug List (PDL) may require PA. Visit our Pharmacy page for the current PDL, and find instructions for requesting PA or a formulary exception through covermymeds.

Notification of determination is communicated in writing to providers and members within established time frames in the Turnaround Times for Service Authorization Requests section below.

All medical necessity adverse determinations are rendered by a medical director. The written adverse determination notification will include the following:

• Rationale
• Reference to the benefit provision, clinical guidelines and/or clinical policy used, and directions on how to obtain a copy
• Opportunity to discuss the determination with a medical director
• Appeal rights

Concurrent review is an assessment of ongoing clinical care to determine if services being provided meet clinical guidelines for the appropriate level of care and setting. Licensed clinical reviewers assess the care and services provided, and the member’s response to the care, by applying InterQual® guidelines.

Inpatient concurrent review supports the coordination of the member’s discharge plan. Meridian’s reviewers work with the facility discharge planners to:

• Identify the member’s discharge planning needs
• Facilitate the transition of the member from one level of care to another
• Obtain clinical information and facilitate the authorization of post-discharge services

Concurrent review may apply to care or services delivered in inpatient or outpatient settings. For inpatient concurrent review requests, if the discharge is confirmed at the time of the initial request/notification of the admission, retrospective review may be applied.

Examples of concurrent reviews:

• A continued stay review for an inpatient facility stay
• A new admission to a facility when the plan is notified after the admission has occurred, but before the member has been discharged
• An extension to a specified course of allergy injections
• An extension to a series of physical or occupational therapy treatments
• A specified plan of continuation of home health services
• Continued rental or purchase of oxygen and its related durable medical equipment (DME)

Clinical information is required for all clinical review requests to ensure timely decisions. The decision time frame is based on the date we receive the supporting clinical information. Include all supporting clinical information with the initial request.

Clinical information includes relevant information regarding the member’s:

• History of presenting problem
• Physical assessment
• Diagnostic results
• Photographs
• Consultations
• Previous and current treatment
• Response to treatment
• Level of care of treatment

Retrospective review is the process of reviewing a request for services that have already been received. Meridian applies the same medical necessity guidelines used for the pre-service decisions and considers the member’s needs at the time of service.

Meridian may make retrospective medical necessity review decisions when:

• A member was discharged from an inpatient admission prior to timely notification to the health plan
• Non-routine obstetrical admissions require additional days of service
• Authorization or timely notification was not obtained due to extenuating circumstances
  
  • Services received prior to the date of notification may be retrospectively reviewed for up to five (5) calendar days if there are extenuating circumstances; dates prior to five (5) calendar days are administratively denied

Meridian does not retroactively authorize services rendered. Follow pre-service review procedures for services that require authorization.

Administrative Days may be requested once the facility receives notification that medical necessity criteria are no longer met and a denial has been issued. Administrative Days provide reimbursement, at a reduced rate, when a member no longer meets medical necessity criteria for the current level of care and there are barriers to discharge. Please note, if Administrative Days are approved, providers waive their appeal rights and may not appeal the medical necessity denial.

Request Administrative Days by faxing supporting documentation to the appropriate number listed below. Label your submission “Administrative Days Request.”

• Standard/Urgent Requests Fax: 833-544-0590
• Behavioral Health Requests Fax: 833-544-1827
• YouthCare (YC) Requests:
  
  • YC Physical Health Fax: 844-989-0154
  • YC Behavioral Health Fax: 833-387-3173

Criteria for Administrative Days consideration include:

• Member is covered by Medicaid.
• Initial admission diagnosis required an acute inpatient level of care.
  
  • Initial admission was authorized by Meridian.
  • Notification requirements were met, and the date and time of the admission and notification should be included with the request.
• A discharge plan to a lower level of care is documented and submitted with the request.
  
  • Barriers to the discharge plan beyond the control of the provider, facility, and/or health plan are documented.
  • The facility has notified Meridian as soon as they believe post-discharge placement will be difficult and has made reasonable efforts to engage the health plan in discharge planning (date of notification, Meridian point of contact, and other pertinent details should be included with the request).

A peer-to-peer discussion is an opportunity for a treating physician to discuss medical criteria and guidelines with the a health plan medical director. Medical directors review cases based on medical information submitted to the health plan.

Treating physicians who would like to discuss a utilization review determination or a request for further documentation with the decision-making medical director may do so at any time during the review process by contacting the Utilization Management department at 833-541-2297. A peer-to-peer discussion performed after an adverse benefit determination may result in an overturn. The request must be submitted within ten (10) calendar days of the initial denial notification. Meridian will work with the treating physician to schedule the peer-to-peer review within three (3) business days of receipt of the request.

Medical directors may verbally notify the provider of their decision during or after the peer-to-peer discussion. All providers will be notified of Meridian’s decision in writing within 24 hours of the peer-to-peer review.

A member, a member’s representative, or provider acting on behalf of the member may appeal a decision made by Meridian to deny, reduce, or terminate a requested service. Review Meridian’s processes for standard and expedited appeals.

If the adverse determination decision is upheld following an appeal, a member or their authorized representatives have the right to request an external independent review (EIR) within 30 days of Meridian’s notification of the appeal decision. Review additional EIR details on the Appeal Process page.

To guide the decision-making process, our team applies systematic evaluations to appropriate medical necessity guidelines and considers circumstances unique to each member.

Service authorization requests apply evidence-based clinical standards of care to determine medical necessity. Use the links below to view medical policies, vendor guidelines, and evidence-based clinical criteria.

• Meridian Clinical and Payment Policies
• American Society of Addiction Medicine (ASAM) Criteria® 
  
  • ASAM criteria are integrated into the Availity prior authorization workflow. Select the Take Me to InterQual button when completing an authorization request.
• McKesson InterQual® guidelines
  
  • In Availity, select the Take Me to InterQual button when completing an authorization request.
• Envolve Dental clinical policy guidelines (Access through the Envolve Dental provider web portal)
• Evolent Clinical Guidelines
  
  • Advanced imaging
  • Cardiology
  • Musculoskeletal surgery
  • Interventional Pain Management
  • Radiation oncology
  • Physical medicine
  • Sleep health
  • Genetic testing
• National Comprehensive Cancer Network (NCCN) Guidelines®

• Utilization Management Report 2025 (PDF)