** IMPORTANT NOTE **

Effective April 1st, 2021
Evicore is no longer receiving requests for cardiology or radiology services. These requests now need to be submitted to NIA, National Imaging Associates, Inc. Requests can be submitted to NIA via the NIA website or by phone at 800-424-5388

Effective January 1, 2021
There will be changes to the authorization submission process for Michigan MeridianComplete (Medicare-Medicaid Plan [MMP] . Please log into the Provider Portal to check authorization requirements, or submit a request. Requests may be submitted via fax to: 844-930-4390 (Inpatient / Post-Acute) or 844-930-4389 (Pre-Service) . Expedited pre-service requests may also be submitted over the phone: 844-239-7387 . Please note: do not utilize the new channels to submit a request for authorization until on or after January 1, 2021 as this transition is not active until then.

AUTH PORTAL PRIOR AUTHORIZATION FORM

For pharmacy authorization requests, visit our Pharmacy Benefit Manager (PBM) website, MeridianRx. (This will open in a new window).

Enter CPT code to determine if authorization process is managed by a Wellcare vendor.

Authorization is required for this service, please continue.

In Correct!

The code you typed in is incorrect. Please check and make sure you have the right code.

No Authorization!

No Authorization required for this service.

Caution!

Requests for pain management, sleep studies, genetic testing and OT/PT services should be routed through eviCore. A complete list of procedure codes requiring review through eviCore can be accessed here. Requests can be submitted to eviCore via the eviCore website, by phone at 888-333-8641, or by fax to 800-540-2406.

Caution!

Requests for radiology and cardiology services should be routed through National Imaging Associates, Inc. (NIA). Requests can be submitted to NIA via the NIA website, by phone at 800-424-5388.

Caution!

Requests for medical oncology and radiation therapy services should be routed through HealthHelp. A complete list of procedure codes requiring review by HealthHelp are available at portal.healthhelp.com/Meridian. Requests can be submitted through the HealthHelp website, by phone 888-285-0562, or fax 866-203-7271.

Caution!

Requests for musculoskeletal surgical procedures should be routed through Turning Point. Requests can be submitted through the Turning Point website. Ohio Providers can also submit by phone 866-611-6951, or fax 833-807-8925. Michigan providers can also submit by phone 877-659-9496, or fax 833-807-8929.

Caution!

WellCare ONLY members (Extra and Essential)
Michigan/Ohio Market Providers: For Medical Pharmacy requests, please log into the Provider Portal to check authorization requirements or submit faxed request to 888-871-0564.

Caution!

For Behavioral Health requests, please log into the Provider Portal to check authorization requirements, or submit a request. Behavioral health requests may be submitted via fax to: 1-855-713-0592 (Inpatient) or 1-855-713-0593 (Outpatient). Inpatient urgent requests can be also be called in to Provider Services (833-857-0929) between 8am-6pmET Monday-Friday.

Procedure Code Check (For Professional services only. All Facility services (Inpatient, SNF, LTACH) require an authorization.) Enter CPT code to determine if authorization process is managed by a Wellcare vendor

ALL EMERGENT ADMISSION REQUESTS ARE REVIEWED WITHIN A 24 HOUR PERIOD

* INDICATES REQUIRED FIELD

REQUESTING INFO

Valid Please Continue

Invalid, please check if the Auth number is correct.

Invalid, please check if a health plan has been selected first.

Select Payor/Health Plan*

Request Type *

Request Category *

Existing Authorization*

Place of Service*

Requesting Service*

Auth Start Date*

Auth End Date*

Reason for urgency* In 150 chracters or less explain the reason for urgent request

Administrative Contact Name*

Requesting Phone*

MEMBER INFORMATION

Member ID*

First Name*

Last Name*

Date of Birth*

REQUESTING PROVIDER/FACILITY INFORMATION

Requesting Provider NPI*

Requesting Last Name / Facility Name*

Requesting First Name

Requesting Address*

Requesting Additional Address

Requesting City*

Requesting State*

Requesting Zip*

Requesting Phone*

Requesting Fax*

Requesting Administrative Contact Name*

SERVICING PROVIDER/FACILITY INFORMATION

Servicing Provider NPI*

Servicing Last Name / Facility Name*

Servicing First Name

Servicing Address*

Servicing Additional Address

Servicing City*

Servicing State*

Servicing Zip*

Servicing Phone*

Servicing Fax*

FACILITY INFORMATION

Facility NPI*

Facility Name*

Facility Address*

Facility Additional Address

Facility City*

Facility State*

Facility Zip*

Facility Phone*

Facility Fax*

AUTHORIZATION REQUEST

CPT/HCPCS*

Qty:*

Auth Start Date:*

Auth End Date*

Add Procedure

CPT lookup list

Add Diagnosis Code

Primary Diagnosis Code*

Diagnosis lookup

(Please note the diagnosis code should be at its highest level of specificity)

FILE UPLOADS

Max file size allowed 50 MB.

(Attach multiple files(.jpg , .png , .bmp, .pdf).)
A electronic submission allows clinical attachments to be made to the Prior Authorization Form and allows the form to be submitted online without printing or faxing.

PROVIDER NOTES

Disclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policies and procedures. Other rules may apply.

Confidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the intended recipient, any use, distribution or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document.

Reset

Instructions

HealthHelp

eviCore

Turning Point

WellCare

WellCare ONLY members (Extra and Essential) Michigan/Ohio Market Providers: For Medical Pharmacy requests, please log into the Provider Portal to check authorization requirements or submit faxed request to 888-871-0564.

WellCare Behavioral Health

NIA

Resource

Click here for information on H3 resources

AUTH PORTAL PRIOR AUTHORIZATION FORM

Enter CPT code to determine if authorization process is managed by a Wellcare vendor.

ALL EMERGENT ADMISSION REQUESTS ARE REVIEWED WITHIN A 24 HOUR PERIOD

* INDICATES REQUIRED FIELD

REQUESTING INFO

MEMBER INFORMATION

REQUESTING PROVIDER/FACILITY INFORMATION

SERVICING PROVIDER/FACILITY INFORMATION

FACILITY INFORMATION

AUTHORIZATION REQUEST

FILE UPLOADS

PROVIDER NOTES

Urgent Request

Please wait while we process your request.

Auth End Date

Invalid Auth End Date

Invalid Auth Start Date

Future DOB

Facility information

Instructions

HealthHelp

eviCore

Turning Point

WellCare

WellCare Behavioral Health

NIA

Resource