Get Authorization Referral Form - Meridian Health Plan

Completing the Authorization Referral Form for Meridian Health Plan may seem daunting, but this guide will provide you with clear and supportive instructions to simplify the process. By following these steps, you can efficiently fill out the form online to ensure that your referrals are processed smoothly.

Follow the steps to successfully complete the Authorization Referral Form.

1. Press the ‘Get Form’ button to access the Authorization Referral Form and begin filling it out.
2. In the 'Patient Information' section, enter the last name, first name, date of birth (DOB), member ID number, and contact information including phone and fax numbers.
3. For the 'PCP Referred By' section, include the last name, first name, phone, and fax of the primary care provider who is making the referral.
4. In the 'Specialist Referred To' and 'Facility Referred To' sections, fill in the relevant names, contact numbers, addresses, and dates of service. Clearly specify the specialty of the services requested.
5. Review the list of services that do not require prior authorization, and mark any applicable options if relevant.
6. In the 'Services That Require Notification to Meridian' section, indicate any services that apply to your situation by checking the appropriate boxes.
7. For the 'Services That Require a Prior Authorization' section, check any necessary services and be aware that clinical information may be requested for some of these.
8. List the procedure codes in the 'Services Requested' area using the appropriate CPT and ICD-9 codes. Provide any additional comments or information that may be relevant.
9. Ensure you have reviewed all entered information for accuracy. Once completed, you can save your changes, download, print, or share the form as needed.

Start completing the Authorization Referral Form online today to ensure your healthcare needs are met promptly.