Get Preauthorization Request Form - Messa - Messa

Filling out the Preauthorization Request Form - Messa is essential for obtaining authorization for medical procedures. This guide provides clear, step-by-step instructions on how to accurately complete this form to ensure a smooth processing experience.

Follow the steps to complete the Preauthorization Request Form - Messa.

1. Click the ‘Get Form’ button to access the preauthorization request form and open it in your editor.
2. In the MESSA Member / Patient Information section, fill in details such as the type of plan, patient's first and last name, date of birth, and MESSA enrollee ID. Also include contact information such as home and business phone numbers, as well as the full address.
3. In the Preauthorization Information section, enter the diagnosis code (ICD-9), procedure code (CPT), and charged amount. If necessary, include any applicable modifiers.
4. Under Performing Physician Information, input the name of the physician and their Tax ID or NPI number. If there is an assistant surgeon, provide that individual’s details as well.
5. Provide the physician's address and scheduled date of surgery, ensuring to include both business phone and fax numbers.
6. Attach any necessary documentation including history & patient notes, information on medical necessity, and photos (if applicable). Note that these attachments will not be returned.
7. Once you have filled out the form and attached all required documentation, follow the instructions to submit your preauthorization request by faxing or mailing it to MESSA Member Services, Attn: PreAuthorization Department.

Complete your preauthorization request forms online for efficient processing.