Documentos y formularios
Assign Your Care Decisions
Advance Directives
Advance Directives are legal records. They are used when you are very sick and cannot explain the kind of care you want. They let your family, friends and doctors know about your end-of-life choices ahead of time.
This document provides information about advanced directives such as a living will and durable power of attorney for health care.
Appointment of Representative Form (CMS-1696)
An appointed representative is a relative, friend, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.
Use this form to appoint a representative to act on your behalf. Once you have completed and signed this form, please mail to the following address:
Meridian
PO Box 3060
Farmington, MO 63640-3822
Greivance & Coverage Decisions
Part C
To file a request for a Medicare Part C (medical care) coverage decision or appeal please call Meridian Member Services at 1-855-580-1689 (TTY: 711), Monday - Friday from 8 a.m. to 8 p.m. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.
- Member Request for Reimbursement (PDF)
Use this form to request reimbursement for medical services that you paid out of pocket for but believe should have been covered by the plan.
- Medicare Grievance Form
Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.
Part D
To file a request for a Medicare Part D (prescription drug) coverage decision or appeal please call Meridian Member Services at 1-855-580-1689 (TTY: 711), Monday - Friday from 8 a.m. to 8 p.m. On weekends and on state or federal holidays, you may be asked to leave a message. Your call will be returned within the next business day.
- Member Request for Reimbursement - English - (PDF)
- Member Request for Reimbursement - Spanish - (PDF)
Use this form to request reimbursement for a prescription/medication that you paid out of pocket for but believe should have been covered by the plan.
- Medicare Grievance Form
Use this form if you have concerns or problems with covered services or the quality of care you receive as a member of our plan.
- Part D Coverage Determination Request Form (PDF)
Use this form to ask us to make a coverage determination and/or prior authorization. Once you have completed and signed this form, please mail to the address below.
Meridian
Attn: Coverage Determination/Appeals
1 Campus Martius, Suite 750
Detroit, MI 48226
- Part D Redetermination Request Form (PDF)
If Meridian denied your request for coverage of (or payment for) a prescription drug, use this form to ask us for a redetermination (appeal) of our decision. Once you have completed and signed this form, please mail to the address below.
Meridian
Attn: Coverage Determination/Appeals
PO Box 3060
Farmington, MO 63640-3822