Get Msa 1653 B Form

Filling out the Msa 1653 B Form online is a crucial task for Medicaid enrolled suppliers and providers seeking prior authorization. This guide offers a clear path to complete the form accurately, ensuring all necessary information is provided.

Follow the steps to complete the Msa 1653 B Form online.

1. Click the ‘Get Form’ button to access the Msa 1653 B Form and open it in your preferred online editor.
2. In Box 1, leave for MDCH use; proceed to Box 2. Enter the provider's name using the specified format: last name, first name, and middle initial.
3. In Box 3, input the NPI (National Provider Identifier) number associated with the provider.
4. Provide the provider's phone number in Box 4 for contact purposes.
5. In Box 5, fill in the provider’s complete address including number, street, suite, city, state, and ZIP code.
6. Enter the provider's fax number in Box 6.
7. In Box 7, input the beneficiary's name in the same format used for the provider's name.
8. Select the beneficiary's sex in Box 8, using 'M' for male or 'F' for female.
9. In Box 9, enter the beneficiary's birth date.
10. Provide the MIhealth card number in Box 10.
11. In Box 11, fill in the beneficiary's address, ensuring all details are complete.
12. In Box 12, indicate if the beneficiary resides in a nursing facility. If 'Yes,' provide the facility's name, address, and phone number.
13. Enter the referring or ordering physician’s name in Box 13, following the same format as previous names.
14. Input the NPI number of the referring physician in Box 14.
15. Provide the referring physician's phone number in Box 15.
16. Fill in the address of the referring physician in Box 16, using the full address format.
17. For each item in Box 17, detail the service requested including the description, brand name, model, and catalog or part number in Box 19.
18. Enter the HCPCS procedure code related to the requested item in Box 20.
19. In Box 21, fill out the applicable HCPCS modifier.
20. List the primary and secondary diagnoses or the CSHCS qualifying diagnosis in Box 24, including both the code and description.
21. Provide any additional remarks in Box 25, such as verbal authorization dates or other insurance coverage information.
22. Complete Box 27 as required for all requests, confirming provider certification and understanding of prior approval necessity.
23. After completing all sections, review the form for accuracy. Save your changes, download, print, or share the form as necessary.

Complete your documents online and ensure timely submission for authorization.