Prior Authorization
Some covered services or medications may need approval from Meridian, 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 memberservices.mi@centene.com or 888-437-0606 (TTY: 711).
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.
Below is a list of services that require prior authorization from Meridian before your healthcare provider can proceed with treatment.
| Services that require a Prior Authorization | Prior Authorization Required for some or all of the Services |
|---|---|
| Immunizations & Vaccines (shots) | Some services may require prior authorization |
| Circumcisions | Some services may require prior authorization |
| Birth Control | Some items may require prior authorization |
| Obstetric and Maternity Care | Some services may require prior authorization |
| Abortions | Yes |
| Medical Inpatient Care | Yes |
| Skilled Nursing Facility | Yes |
| Inpatient Rehabilitation | Yes |
| Long Term Acute Care Hospital | Yes |
| Cardiac and Pulmonary Rehab | Some services may require prior authorization |
| Home Health Care | Yes |
| Specialty Care (Office Visits and Clinics) | Yes |
| Diagnostic Testing Urinalysis and Urine Cultures | Yes |
| Radiology Services (X-rays) | Some services may require prior authorization |
| Rehabilitative/Habilitative Services and Devices | Some services may require prior authorization |
| Hearing Aids | Yes |
| Asthma Supplies | Some items may require prior authorization |
| Prosthetics/Orthotics | Some items may require prior authorization |
| Medical Supplies | Some items may require prior authorization |
| Durable Medical Equipment (Wheelchairs, walkers, hospital beds, etc.) | Some items may require prior authorization |
| Non-emergent, Inpatient, Ambulatory, Outpatient, Emergency and Reconstructive Surgeries | Some services may require prior authorization |
| Transplants | Yes |
| Hospice Care | Yes |
| Eye Care and Eyeglasses | Some services may require prior authorization |
| Diabetes Care | Some services may require prior authorization |
| Prescription and Over the Counter (OTC) Drugs | Some items may require prior authorization |
| Weight Management (WM) | Yes |
| Pain Management Injections | Some services may require prior authorization |
| Miscellaneous, unlisted, or no other specified procedures | Yes |
| Specialty care (office visits and clinics) | Some services may require prior authorization |
| Diagnostic Testing Urinalysis and Urine Cultures | Some services may require prior authorization |
| Non-emergent Out of State Care | Some services may require prior authorization |