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Michigan Department of Health and Human Services Practitioner Special Services Prior Approval Request/Authorization Completion Instructions The MSA6544B must be used by Medicaid enrolled providers.

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All PA requests should be submitted electronically, via CHAMPS. For questions regarding FFS Prior Authorization, call the Program Review Division at 1-800-622-0276. If CHAMPS is inaccessible, requests may be faxed to 517-335-0075.

General Contact Information 517-335-8448 (phone) 517-335-8835 (fax) 1-800-942-1636 (toll-free) 517-335-8951 (voc)

What to bring to your DHS appointment Proof of Income. Pay Stub(s) from the last 30 days. Bank Statement from the last 30 days. Social Security awards letter. Tax Return. Unemployment letter. Social Security Number. Identification. Driver's License. State ID. Proof of Address. ID with current address. Utility Bill.

The healthcare provider is usually responsible for initiating prior authorization by submitting a request form to a patient's insurance provider. As mentioned in the “How does prior authorization work?” section above, this will then often prompt a time-consuming back and forth between the provider and payer.

A Michigan Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug prescription in the state of Michigan. In this form, the physician provides their clinical reasoning for making this request instead of prescribing a drug from the Preferred Drug List (PDL).

Medicaid requires prior authorization (PA) to cover certain services before those services are rendered to the beneficiary. The purpose of PA is to review the medical need for certain services. It does not serve as an authorization of fees or beneficiary eligibility.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232