Glossary of Program Terms

Listed below are commonly used terms when describing Meridian’s service authorization program.

Administrative days: Inpatient hospital days (sometimes referred to as hospital long term care days) for members determined to no longer meet medical necessity criteria for the current level of care, and there are barriers to discharge that prevent the member from stepping down to a lower level of care (such as unavailability of beds or unique medical circumstances). See Administrative Days section of the Service Authorization Program page for additional details
Adverse benefit determination: A determination made by Utilization Management reviewers or a vendor solution organization that, based upon the information provided, a request for a benefit under the member’s plan does not meet requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness—or is determined to be experimental or investigational. The requested benefit is therefore denied, reduced, or terminated
Appeal: A request to review an adverse benefit determination to deny, reduce, or terminate a requested service. Members and their authorized representatives may classify their appeal request as standard or expedited (for clinically urgent situations). See Appeal Process page for additional details
ASAM: The American Society of Addiction Medicine (ASAM) Criteria is a comprehensive set of standards and decision rules that use a holistic, person-centered approach to determining the appropriate level of care and developing treatment plans for patients with addiction and co-occurring conditions
Authorized representative: Any person other than the member, such as a friend, family member, or attorney, who has been given express written consent to represent the member in service authorization program processes
Availity Essentials™: A secure, multipayer provider portal supporting a variety of tasks, such as verifying eligibility and member benefits, submitting pre-service review requests, and accessing proprietary clinical review guidelines
Clinical guidelines/clinical review guidelines: Written screening procedures, decision abstracts, clinical protocols, and practice guidelines used to determine the necessity and appropriateness of health care services
Concurrent review: A type of service authorization program that reviews ongoing clinical care to determine if the services that are being provided meet the clinical guidelines for the appropriate level of care and setting. See Concurrent Review section of the Service Authorization Program page for additional details
External Independent Review (EIR): The process of having a decision reviewed by an independent review organization not associated with the health plan following an appeal of an adverse benefit determination. In clinically urgent situations, members and their authorized representatives may file a request for an expedited EIR. EIR is not permitted for Home and Community-Based Services. See the Appeal Process page for additional details
InterQual®: A system of proprietary, evidence-based clinical criteria and decision support tools used to determine the appropriate level of care, length of stay, and medical interventions for patients
Medical necessity: A service that addresses the specific needs of a member for the purpose of: (1) Screening, preventing, diagnosing, managing, or treating an illness, injury, or condition and disorder that results in health impairments and/or disability or its symptoms and comorbidities; (2) Minimizing the progression of an illness, injury, or condition or its symptoms and comorbidities; (3) achieving age-appropriate growth and development; or (4) attaining, maintaining, or regaining functional capacity. The service is in a manner that is: (1) in accordance with generally accepted standards of care; (2) clinically appropriate in terms of type, frequency, extent, site, and duration; and (3) not primarily for the economic benefit of the MCO or for the convenience of the enrollee or provider
Notification: The process for alerting Meridian when a member is admitted to a facility for certain services requiring notification, such as inpatient substance use disorder treatment
Peer-to-peer review: An opportunity for a treating physician to discuss an adverse benefit determination and associated clinical review guidelines regarding medical, behavioral health, or pharmacy services with a physician reviewer. See Peer-to-Peer Review section of the Service Authorization Page for additional details
Pre-service review (prior authorization): A process used to review medical information before the delivery of requested healthcare services to determine if the care and setting are medically appropriate and according to established guidelines. See Pre-Service Review section of the Service Authorization Program page for additional details
Retrospective review: The process of reviewing a service request and making an organizational determination after a service has been rendered by a provider. See Retrospective Review section of the Service Authorization Program page for additional details
Secure provider portal: Meridian’s secure provider portal that offers a variety of tasks, such as verifying eligibility and member benefits, submitting pre-service review requests, and accessing proprietary clinical review guidelines
Service authorization program: Describes the utilization management activities conducted to ensure the medical services provided to members are medically necessary and/or appropriate, conform with the plan benefits, and engage Care Coordination team when appropriate. Meridian’s service authorization program consists of pre-service review (prior authorization), concurrent review, and retrospective review. See Service Authorization Program page for additional details
State Fair Hearing: Following a notice of appeal resolution, members or their authorized representatives may request a hearing conducted by an impartial Hearing Officer designated by the appropriate state agency. See the Appeal Process page for additional details
Utilization Management (UM): A health plan process focused on ensuring the medical services provided to members are medically necessary and/or appropriate, conform with the plan benefits, and engage care coordination teams when appropriate
Vendor solutions: Third-party utilization review organizations designated to perform pre-service review for certain services. See Pre-Service Review section of the Service Authorization Program page for additional details