Client Referral Resources

Find the documents are for the updated Out of Network/Non-Certified (OON) Referral process. This is only for clients who are not receiving medical case management from the local Part A/MAI Program.

The first two documents listed below are fillable online. However, they need to be printed and signed (referral form only) by the client. Then, the client gives these forms to the agency where services are needed. See the OON Registration Contact Information list below. Supporting documentation, as shown on the checklist, must be attached to the referral.

The Part A/MAI Program is the payer of last resort. Attach to the referral proof that the service or procedure was not covered by any other source.

• Out of Network (OON) / Non-Certified Referral (Final 04/23/18)
• Out of Network (OON) / Non-Certified Referral Demographics (Revised 4/29/19)
• Client Eligibility Documentation Checklist Summary (Effective 06/01/23)
• Client Eligibility Documentation Checklist Detail (Effective 06/01/23)
• Out of Network (OON) Referral Registration Contact Information (Revised 05/01/19)
• 2024 Federal Poverty Guidelines Transmittal Letter
• 2024 Federal Poverty Guidelines