Get Msa 1680-b. Dental Prior Approval Authorization Request - Michigan

The MSA 1680-B form is essential for people with Medicaid coverage seeking dental services in Michigan. This guide provides clear, step-by-step instructions to help users accurately complete the form online.

Follow the steps to effectively complete the MSA 1680-B form.

1. Press the ‘Get Form’ button to access the MSA 1680-B form and open it in your preferred document editor.
2. Begin filling out the form by entering the provider's details, including the provider's name, street address, and county in the designated fields.
3. Next, provide the beneficiary's information, including their name, birth date, sex, and MI Health Card number. Ensure that all details are correctly entered to avoid processing delays.
4. Indicate whether the patient lives in a nursing home and, if applicable, include the facility name. Also, disclose if the patient is covered by any other dental plan.
5. For beneficiaries enrolled in Children’s Special Health Care Services, supply the relevant ICD diagnosis codes and descriptions in the specified sections.
6. If any x-rays are required, check the appropriate box and provide the number of x-rays attached along with the dates they were taken.
7. Indicate if the treatment is for orthodontics and whether a treatment plan is enclosed. Fill in any additional details regarding dental procedures needed.
8. Complete the examination and treatment record fields by accurately describing the services being requested, ensuring to include procedure codes.
9. Review all entries made on the form for accuracy before proceeding. Once confirmed, sign in the provider certification section and include the date.
10. After completing the form, you can save your changes, download a copy, print it out, or share it as needed for submission.

Start filling out your MSA 1680-B form online today for efficient processing!