Documents and Forms

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:

MeridianComplete
777 Woodward Ave, Suite 700
Detroit, MI 48226

Grievance & Coverage Decisions

Part C

To file a request for a Medicare Part C (medical care) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. 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)
Member Reimbursement Form & Foreign Claim Questionnaire (PDF) - coming soon
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.

Part D

To file a request for a Medicare Part D (prescription drug) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. 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 (Prescription Medication) (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.

MeridianComplete
Attn: Coverage Determination/Appeals
777 Woodward Ave, Suite 700
Detroit, MI 48226

Gas Mileage Reimbursement Forms

• The Medical Transportation Statement Form will have 3 new items to be filled out by the transportation provider in section 2. Everything else will remain the same. In order to receive Non-Emergency Medical Transportation gas mileage reimbursement, please complete this form Medical Transportation Statement Form (PDF)

• Family members with road offences can get NEMT payment for members that can consent, but you need to sign and complete NEMT Personal Choice Acknowledgement form (PDF)

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:

MeridianComplete
777 Woodward Ave, Suite 700
Detroit, MI 48226

Grievance & Coverage Decisions

Part C

To file a request for a Medicare Part C (medical care) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. 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)
Member Reimbursement Form & Foreign Claim Questionnaire (PDF) - coming soon
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.

Part D

To file a request for a Medicare Part D (prescription drug) coverage decision or appeal please call MeridianComplete Member Services at 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. 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 (Prescription Medication) (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.

MeridianComplete
Attn: Coverage Determination/Appeals
777 Woodward Ave, Suite 700
Detroit, MI 48226

Gas Mileage Reimbursement Forms

• The Medical Transportation Statement Form will have 3 new items to be filled out by the transportation provider in section 2. Everything else will remain the same. In order to receive Non-Emergency Medical Transportation gas mileage reimbursement, please complete this form Medical Transportation Statement Form (PDF)

• Family members with road offences can get NEMT payment for members that can consent, but you need to sign and complete NEMT Personal Choice Acknowledgement form (PDF)

Michigan Department of Health & Human Services (MDHHS) Consent to Share Behavioral Health Information Form

When you receive health care, your health care provider and health plan keep records about your health and the services you receive. This information becomes part of your medical record. This form can be used to give or take away consent to share information about your Behavioral Health services and/or substance use disorder.

Last Updated: 10/01/2023

H0480_WEBSITE_2024 Pending Accepted on 9/26/2023

Last Updated: 10/01/2023

H0480_WEBSITE_2024 Pending Accepted on 9/26/2023

MeridianComplete (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the MeridianComplete Member Handbook. Out-of-network/non-contracted providers are under no obligation to treat MeridianComplete members, except in emergency situations. Please call our Member Services number or see your Member Handbook for more information, including the cost-sharing that applies to out-of-network services. For information on MeridianComplete and other options for your health care, call Michigan ENROLLS at 1-800-975-7630 (TTY: 1-888-263-5897). Office hours are Monday through Friday, 8 a.m. to 7 p.m. You can get this document for free in other formats, such as large print, braille, or audio. Call 1-855-323-4578 (TTY: 711), 8 a.m. to 8 p.m., seven days a week. 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. The call is free.

Other pharmacies/providers are available in our network.

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