Get Michigan Form Dch 0893

Filling out the Michigan Form Dch 0893 online is essential for Medicaid enrolled vision providers seeking prior approval for vision services and the ordering of optical hardware. This guide will provide you with a clear and supportive approach to completing the form accurately and efficiently.

Follow the steps to complete the Michigan Form Dch 0893 online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering the date the service and/or hardware is being ordered in item 4. Ensure the date follows the format MM/DD/YYYY.
3. In items 2-3, provide the ordering provider's full name as well as the NPI number.
4. Fill in the address of the ordering provider in item 5, including street number, street name, city, state, and ZIP code.
5. Complete the contact information by entering the provider's fax number in item 6 and phone number in item 7.
6. In items 8-9, enter the individual prescribing provider’s full name and NPI number.
7. The beneficiary’s information must be filled out in items 11-15. This includes the beneficiary’s name, birth date, mihealth card number, address, and sex.
8. Proceed to item 16 and provide the ICD diagnosis code which reflects the most specific diagnosis. Include details for each eye if applicable.
9. In items 17-21, describe the services and materials being requested by filling in the procedure code, modifier, quantity of items, and charge for each request.
10. Specify the type and style of lens requested in items 22-24, ensuring you provide information about the frame as well.
11. Detail all lens specifications in item 25. Ensure the specifications align with the selected procedure code.
12. Include any additional instructions to the vision contractor in item 26.
13. If applicable, fill in specifications from any previous lenses in item 27.
14. Review the information filled in and ensure all necessary fields have been completed to facilitate processing.
15. Once completed, retain a copy of the finished form for your records before submitting it to the appropriate addresses provided for prior approval or optical orders.

Start filling out the Michigan Form Dch 0893 online to ensure a smooth approval process for vision services.