Appeal Process
An appeal is a request for review of a decision made by Meridian to deny, reduce, or terminate a requested service. Examples include:
- A service was denied based upon medical necessity
- A service was denied (such as physical therapy) that was previously authorized
Standard and Expedited Appeals
A member or their representative, such as a provider, family member, friend, or attorney, may file an appeal on the member’s behalf with the member’s written permission. The member must submit written permission to Meridian for an authorized representative to appeal on their behalf. Written permission can be provided by submitting an Authorized Representative Designation Form (PDF).
Members or their authorized representatives have 60 days from the date of the Adverse Benefit Determination letter to file an appeal verbally or in writing.
Members or their authorized representatives can file a standard or expedited appeal by calling Member Services at 866-606-3700 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., by fax, or in writing to the appropriate address listed below. Please note that appeals for behavioral health services and pharmacy requests are managed separately from appeals for other healthcare services.
Meridian Member Appeals (Non-Rx and Non-Behavioral Health Services) | Behavioral Health Services and Appeal | Pharmacy Appeals |
|---|---|---|
Meridian Member Appeals Dept. | Centene Behavioral Health Appeals (denied auth on file) | Meridian Pharmacy Appeals |
Within three (3) business days of receiving the appeal, Meridian will confirm receipt in writing. We will make a decision about the appeal and notify the member and their PCP, as well as any other providers involved in the appeal, in writing within 15 business days of receiving all required information.
Members seeking continuation of existing services during the appeals process must notify Meridian within 10 days of the Adverse Benefit Determination Letter date. Meridian must continue the member’s benefits during the appeal process. A provider, serving as a member’s authorized representative for the appeal process, cannot file for continuation of benefits. If the final resolution of the appeal is adverse to the member, Meridian may recover the cost of services that were furnished to the member.
If a situation is clinically urgent and reviewing the appeal in the standard time frame would jeopardize the member’s life or well-being, a member or their provider can request an Expedited Appeal. Requests that do not meet these criteria will be processed within the standard time frame.
Meridian medical directors will make a decision about the appeal within 24 hours of receiving all required information. The member and their provider will be notified verbally of the outcome of the appeal. A written notification will also follow.
All member expedited appeals may be sent to the Member Appeals department fax number or mailing address noted below.
Meridian Member Appeals (Non-Rx and Non-Behavioral Health Services) | Behavioral Health Services and Appeal | Pharmacy Appeals |
|---|---|---|
Meridian Member Appeals Dept. | Centene Behavioral Health Appeals (denied auth on file) | Meridian Pharmacy Appeals |
External Independent Review (EIR)
(Home and Community-Based Services excluded)
If an adverse benefit determination is upheld following a standard or expedited appeal, members or their authorized representatives have the right to request an external independent review (EIR). Members must request an EIR within 30 days of Meridian’s notification of the appeal decision. An EIR request or an expedited EIR request may be sent to the Member Appeals department by fax or to the mailing address noted below.
Meridian Member Appeals (Non-Rx and Non-Behavioral Health Services) | Behavioral Health Services and Appeal | Pharmacy Appeals |
|---|---|---|
Meridian Member Appeals Dept. | Centene Behavioral Health Appeals (denied auth on file) | Meridian Pharmacy Appeals |
The right to request an EIR process is reserved for members after completion of an appeal regarding a prior authorization denial. EIR is not available for providers regarding claims payment, handling, or reimbursement for covered services. Meridian will not consider EIR requests by providers made on behalf of members after services are rendered. The reviewer will make a decision about the appeal within five (5) days of receiving all required information.
If the member’s situation is clinically urgent, the member or a provider acting on behalf of the member may call Member and Provider Services at 866-606-3700 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m., to file an expedited request for EIR.
The reviewer will make a decision within 24 hours of receiving all required information. The member and their PCP, as well as any other provider involved in the case, will be notified verbally of the outcome of the appeal. A written notification will also follow.
State Fair Hearing
Final decisions of appeals, including expedited Appeals, not resolved wholly in favor of the enrollee may be appealed by the enrollee to the State under its fair hearings system within 120 days after the date of Meridian’s decision notice. The adverse determination letter will outline the procedure for requesting a fair hearing.
For additional information on how to request a State Fair Hearing, consult the provider manual or member handbook.