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How to fill out the MSA 115 Form online
Filling out the MSA 115 Form online is a crucial step for providers requesting prior authorization for therapy services. This guide will walk you through each section of the form, ensuring that you are well-prepared to submit your request accurately.
Follow the steps to successfully complete the MSA 115 Form online.
- Click the ‘Get Form’ button to obtain the MSA 115 form and open it in your editor.
- Provide the prior authorization number issued by the Michigan Department of Community Health (MDCH) in Box 1, as necessary.
- Enter the Medicaid enrolled provider’s name, provider type code, and seven-digit identification number in Boxes 2-4.
- Fill in the provider’s telephone number and mailing address in Boxes 5-6, ensuring accuracy.
- In Boxes 7-10, input the beneficiary's name, sex, Medicaid ID number, and birth date as per the information on the mihealth card.
- Record the date the beneficiary was most recently admitted to the hospital or facility in Box 11.
- Specify the diagnosis for which therapy is required in Box 12 and enter the date of onset in Box 13.
- Complete Boxes 14-16 with the therapist’s name, office phone number, and applicable license or certification number.
- In Box 17, indicate whether the treatment is an initial or continuing request.
- List the treatment months in Box 18 and any relevant previous treatment dates in Boxes 19-20.
- Complete Boxes 21-23 with the number of previous sessions and detailed goals and progress summaries for treatment.
- Fill out details regarding school therapy programs and HCPCS codes in Boxes 24-28.
- Ensure the attending physician certifies in Box 29 and that an authorized representative signs in Box 30.
- Finally, check all entries for accuracy and completeness, then save changes, download a copy, print the form, or share it as needed.
Start completing your MSA 115 Form online today for a streamlined prior authorization process.
To enter a modifier on the claim form, you will need to locate the specific field designated for modifiers on the Msa 115 Form. Modifiers provide additional information about the service provided, which is crucial for accurate billing. This detail can influence your reimbursement and service documentation, so careful attention is needed when filling it out.
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