Get Managed Care Out-of-network Request Form

Filling out the Managed Care Out-of-Network Request Form can be straightforward if you understand the components and requirements. This guide provides clear, step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to complete your request form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date at the top of the form. This will help track when the request is made.
3. Indicate whether the member has an out-of-network benefit by selecting 'Yes' or 'No.' If 'Yes,' you do not need a referral.
4. Provide the member's information in the designated fields, including their name, BCBSMA ID number, date of birth, telephone number, diagnosis, and date of injury (if applicable).
5. Fill in the referring provider's information, including their name, signature, referral contact name, and telephone number. Specify if the primary care provider (PCP) has authorized this referral by selecting 'Yes' or 'No.'
6. Enter the national provider identifier (NPI) of the referring provider, along with their secure fax number, confirming if it meets HIPAA requirements.
7. Provide details about the out-of-network provider or facility, including the requested service, date of service, number of visits requested, name, address, specialty, NPI, and telephone number. Again, confirm the secure fax number for HIPAA compliance.
8. Describe the history of present illness, including duration, frequency, severity, and treatment provided, in the space provided.
9. Indicate whether you have accessed the BCBSMA Managed Care Provider Directory to find a participating provider. Select 'Yes' or 'No.' If 'No,' provide the reason for seeking an out-of-network provider.
10. Explain the treatment options the non-participating provider offers that are not available in-network.
11. Indicate whether the requested care is elective by selecting 'Yes' or 'No.'
12. If necessary, use additional pages for notes or further information.
13. Once you have completed the form, ensure all information is accurate. Save your changes, then download, print, or share the form as needed.

Complete your Managed Care Out-of-Network Request Form online to ensure proper processing of your care.