Iowa Referral Form - Meridian Health Plan
Download a blank fillable Iowa Referral Form - Meridian Health Plan in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Iowa Referral Form - Meridian Health Plan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Iowa Referral Form
Fax all Authorizations and
clinical
Date:
/
/
information to:
515-802-3560
or submit online at
NPI #:
TID #:
PATIENT INFORMATION
PCP NAME
Last Name :
First Name:
Last Name :
First Name:
Phone: (
)
-
DOB (
):
/
/
Phone: (
)
-
Fax: (
)
-
MM/DD/YYYY
Member ID#:
Address:
Office Contact:
Address:
SPECIALIST REFERRED TO
FACILITY/PROVIDER NAME
Last Name :
First Name:
Facility Name:
Phone: (
)
-
Fax: (
)
-
Phone: (
)
-
Start:
/
/
End:
/
/
Fax: (
)
-
Address:
Specialty:
Date of Service:
/
/
Address:
SERVICES THAT DO NOT REQUIRE A PRIOR AUTHORIZATION
Allergy Testing, Bone Density, Chiropractic Services (up to 12 visits), ECG, Life Threatening Services, Mammogram & Pap, OB/
GYN Services, Routine Lab, Routine X-Ray, (MRA, MRI, PET Scan, CT Scan), Sleep Studies (facility only), Stress Tests,
Ultrasounds, Urgent Care. Behavioral Health, Psychiatric and Substance Abuse services in all settings are covered by Magellan
Health Services of Iowa. Please call 800-638-8820 for information about these services or visit
SERVICES THAT REQUIRE NOTIFICATION TO MERIDIAN HEALTH PLAN
Outpatient Radiation Therapy
Maternity Care/Maternal Support Services
Dialysis
Observations
SERVICES THAT REQUIRE A PRIOR AUTHORIZATION (
)
may require clinical information
Ambulance Transportation (non-emergent)
Elective Inpatient Admission
Anesthesia when performed with Radiology Testing
Elective Outpatient Surgery
Bariatric Surgery
Genetic Testing/Sterilization
Cardiac/Pulmonary Rehab
Hearing Aids
Chiropractic Services (over 12 visits)
Home Health Care/Hospice/IV Therapy
Cosmetic, Reconstructive or Plastic Surgery
Pregnancy Termination
DME/Prosthetics and Orthotics >$500
Speech, Occupational and Physical Therapy
SERVICES REQUESTED
CPT Code
CPT Code
ICD 9/ICD
# of Visits Requested:
10 Code
CPT Code
CPT Code
Comments: __________________________________________________________
____________________________________________________________________
____________________________________________________________________
CPT Code
CPT Code
____________________________________________________________________
All Emergency Inpatient Admissions require authorization from Meridian Health Plan. For authorization,
Meridian must be notified within the first 24 hours or the following business day.
By requesting prior authorization, the provider is representing that the services to be provided are medically necessary. As a
condition of authorization for those services, the servicing provider agrees to accept no more than 100% of Iowa Medicaid rates. At
no time will Meridian Health Plan pay more than 100% of Iowa Medicaid rates for any service. In the event that these services are
deemed not to be medically necessary, Meridian Health Plan will not reimburse the provider for those services.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical