Get Msa-1302 Beneficiary Monitoring - Meridian Health Plan

Filling out the MSA-1302 Beneficiary Monitoring form is a crucial step for individuals seeking referrals for medical services. This guide provides clear and detailed instructions to help you complete the form accurately online.

Follow the steps to fill out the MSA-1302 form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section 1, Beneficiary Information. Enter the beneficiary's full name, MIhealth ID number, street address, home telephone number, city, state, ZIP code, and an alternate telephone number if applicable. Ensure all details are accurate to avoid any processing delays.
3. Move to Section 2, Primary Care Provider Information. Fill in the provider's name, Primary Care Provider ID number, business address, NPI number, city, state, ZIP code, and telephone number. This information should correspond with the provider services rendered.
4. Proceed to Section 3, Referred Provider and Appointment Information. List the name of the referred provider, date and time of the first appointment, business address, city, state, ZIP code, telephone number, referred provider Medicaid ID number, and NPI number. Carefully verify the details of the appointment to ensure a smooth transition to the new provider.
5. Complete Section 4, Reason for Referral and Authorization. The primary care provider must sign here, certifying the need for referral. Include the date of authorization as well.
6. After completing all sections, review the entire form for accuracy before finalizing. It is advisable to make photocopies for the Primary Provider File and the Referred Medical Provider File.
7. Save changes, download, or print the form as needed. Ensure the original form is mailed to the MSA, Beneficiary Monitoring Program at the following address: Medical Services Administration, PO Box 30479, Lansing MI 48909-7979.

Complete your documents online to ensure a hassle-free referral process.