To:
Behavioral Health Providers
From:
Meridian Health Plan Behavioral Health Department
State:
New Hampshire
Line of Business:
Medicaid
Date:
February 26, 2014
Re:
Updated Behavioral Health Prior Authorization Form Now Available
EFFECTIVE 60 DAYS FROM DATE ABOVE
Meridian Health Plan has updated a Behavioral Health Prior Authorization Form to help
streamline and expedite prior authorization requests. The form is available online at
www.mhplan.com/nh under Documents & Forms. Please contact the Behavioral Health
department if you have any questions regarding this form or Meridian’s authorization process at
855-291-5218.
Providers may always verify member eligibility by using the following resources:
 NH MMIS Health Enterprise Portal: You can verify your patients’ eligibility information
online at: https://nhmmis.nh.gov/portals/wps/portal/enterprisehome
 Meridian Health Plan Provider Portal: If you have already registered for our provider
portal or would like to sign up, you can check eligibility 24/7 at
http://www.mhplan.com/nh/mcs
If you have any additional questions or concerns, please contact your local Provider Network
Development Representative or:
 For general questions, call the Provider Services department at 877-480-8250
 For Member Services, call 855-291-5221 or fax 603-263-3901
 For urgent behavioral health questions, call 855-291-5218 or fax 603-263-3447
Confidentiality Note: This fax contains information from Meridian Health Plan, which may be confidential, legally privileged, or otherwise
protected from disclosure. This information is intended for the use of the addressee only. If you are not the intended recipient, you are
hereby notified that any disclosure, copying, distribution, printing or any other use of, or any action in reliance on, the contents of this fax
is strictly prohibited. If you have received this communication in error, please notify us by phone at 313-324-3700.
www.mhplan.com
New Hampshire Behavioral Health Prior Authorization Form
Date:
/
Fax all authorizations and
supporting clinical
information to:
603-263-3447
/
NPI #:
TID #:
Last Name :
Phone: ( )
Member ID#:
Address:
PATIENT INFORMATION
First Name:
DOB: / /
Last Name :
Phone: ( )
Address:
Specialty:
PROVIDER INFORMATION
First Name:
Fax: ( )
Office Contact:
SPECIALIST/FACILITY REFERRED TO
Specialist Name (Last, First):
Fax: ( )
End:
/
/
Specialty:
Facility Name:
Phone: ( )
Start:
/
/
Address:
SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION
Individual Psychotherapy, Group Psychotherapy and Family Therapy provided by a psychiatrist. Psychotherapy services provided by
psychotherapy providers other than psychiatrists are limited to 18 visits per year for members 21 and older, and 24 visits for
members under 21 years of age.
SERVICES THAT REQUIRE NOTIFICATION TO MERIDIAN
Involuntary emergency admissions to NH Hospital/DRF
Intensive Outpatient Program for members under 22
SERVICES THAT REQUIRE PRIOR AUTHORIZATION
Bilateral Electroconvulsive Therapy (ECT)
Psychological Testing (>6 hours in a 6 month period)
Unilateral Electroconvulsive Therapy (ECT)
Neuropsychological Testing (>6 hours testing in a 6 month period)
Psychological Testing (1st 6 hours in a 6 month period)
Developmental Testing (1st 6 hours in a 6 month period)
Neuropsychological Testing (1st 6 hours in a 6 month period)
SERVICES THAT REQUIRE PRIOR AUTHORIZATION FOR NON-BBH ELIGIBLE MEMBERS
Additional Outpatient visits beyond service limits
SERVICES THAT REQUIRE PRIOR AUTHORIZATION FOR BBH ELIGIBLE MEMBERS
Additional Outpatient visits beyond service limits for low utilizers
CMHC Service Providers: Refer to your provider agreement and to the Meridian Provider Manual for a complete list of prior authorized services, Billable Provider Types and codes.
SERVICES REQUESTED
CPT Code
CPT Code
ICD 9/ICD 10 Code:
# of Visits Requested:
CPT Code
CPT Code
CPT Code
CPT Code
Comments: _______________________________________________________________________________________________
_________________________________________________________________________________________________________
The following services are not covered benefits under Medicaid, but are not limited to:





Psychological or Neuropsych testing ordered for—Forensic Evaluation, Custody Determination
or Placement, Academic or Educational Determinations
Services or items free to the public
Services provided by halfway houses
Detoxification services provided outside an acute care facility or medical service clinic
Please see the Meridian Provider Manual for a complete service list of non-covered services
FORM45 NH—Rev. 20140224
All Voluntary Inpatient
Admissions require
authorization from Meridian
Health Plan. Please refer to
the Meridian Provider
Manual for details.
PAGE 1 of 2
New Hampshire Behavioral Health Prior Authorization Form
Fax all authorizations and
clinical information to:
603-263-3447
Phone: 855-291-5218
Please summarize briefly and attach supportive clinical documentation:
RECIPIENT HISTORY:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
LEVEL OF FUNCTIONAL IMPAIRMENT:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
WHY ARE THE SERVICES MEDICALLY NECESSARY?:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
TREATMENT PLAN (Include time frames and progress information):
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
ARE THERE EXTENUATING CIRCUMSTANCES? IF YES, PLEASE ADVISE:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Signature:
Name/Title (Print):
By requesting prior authorization, the provider is representing that the services to be provided are medically necessary. As a
condition of authorization for services, the servicing provider agrees to accept no more than 100% of New Hampshire Medicaid rates. At no time will Meridian Health Plan pay more than 100% of NH Medicaid rates for any service. In the event
that these services are deemed not to be medically necessary, Meridian will not reimburse the provider for those services.
FORM45 NH—Rev. 20140224
PAGE 2 of 2