Get Messa Ppo Referral Form

Filling out the Messa PPO Referral Form online is a crucial step for PPO members who are being referred to services outside of their network. This guide will provide you with detailed, step-by-step instructions for completing each section of the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of referral by selecting the applicable month, day, and year. This information is essential for the referral's validity.
3. Provide the subscriber name and member's last and first names. Ensure that the information matches the records held by the PPO.
4. Fill in the non-PPO practitioner, facility, or laboratory name and their complete address, including state, city, and zip code.
5. Record the contract number and the member's date of birth, as this information links the referral to the correct PPO member.
6. Input the telephone number for the non-PPO practitioner or facility to enable contact when necessary.
7. Enter the referring PPO practitioner, facility, or laboratory name along with its address.
8. Record the referring practitioner's PIN digits 3 through 9 and the referring facility's 5-digit BCBSM facility code.
9. Include the ten-digit National Provider Identifier of the referring provider.
10. Document the reason for referral, anticipated date of service, length of treatment, and the number of visits required.
11. If applicable, complete the section for the referred practitioner, facility, or ancillary provider including the location, date of service/start date, end date, and specific services requested.
12. Record the ICD-9 diagnosis code and description related to the referral.
13. Ensure all required signatures are obtained, including the signature of the patient or authorized person, the PPO referring practitioner, and the non-PPO provider.
14. Once completed, you can save your changes, download, print, or share the filled form as needed.

Take action now and complete your Messa PPO Referral Form online to ensure your services are processed smoothly.