Medical Claims

Sample Claim Form

A standardized Health Insurance Claim Form can be completed and mailed with provider receipt(s) for benefit reimbursements (See Sample Claim Form).

Claims Reimbursement Form

This form should be completed by the member and mailed with provider receipt(s) for benefit reimbursements.

Medco Health Prescription Fax Form

This form should be completed by your physician and faxed to Medco Health for home delivery pharmacy service.

Medco Health Prescription Mail Order Form

This form should be completed by the member and mailed with the prescription and medical questionnaire to Medco Health for home delivery pharmacy service.

Medco Health, Allergy and Medical Questionnaire

This form should be completed by the member and mailed with the Rx order form to Medco Health for home delivery pharmacy service.

PPO Referral Form

This form should be used when you are being referred for services to a non-PPO physician, hospital or laboratory.

Preauthorization Request Form

This form should be completed by your physician and mailed to the MESSA Member Services Department for authorization prior to services being performed.

Request for Transitional Care Form

This form should be used to apply for transitional care for ongoing treatment with a non-network provider.

Member Appeal Form

1475 Kendale Blvd., P.O. Box 2560, East Lansing, MI 48826