Get Mi Msa-115 2012

The MI MSA-115 form is essential for requesting prior authorization for therapy services through Medicaid. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to fill out the MI MSA-115 form online.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. In Box 2 and 3, enter the name of the Medicaid enrolled provider and the provider’s National Provider Identifier (NPI). Ensure the name is accurate to prevent any processing delays.
3. In Box 4 to 6, fill in the provider's telephone number, address, and fax number. Make sure to include the area codes for both phone and fax.
4. For Box 7 to 10, complete the beneficiary's name, sex, mihealth card number, and birth date in the MM/DD/YYYY format. This information should match that on the mihealth card.
5. In Box 11, input the date the beneficiary was last admitted to a hospital or facility. Accurate dates are critical for determining treatment eligibility.
6. Box 12 requires the diagnosis codes and descriptions related to the requested service. Be precise and use codes from the most current resources.
7. Fill in Box 13 with the date of onset for the beneficiary’s diagnosis, including the date of exacerbation if applicable.
8. In Box 14 to 16, provide the therapist's name, their office phone number, and their license or certification number.
9. Select whether this request is an initial or continuing treatment authorization in Box 17.
10. Enter the last authorization date in Box 18 for the diagnosis in question.
11. Box 19 asks for the treatment months in a two-digit format. Clearly state the calendar months requested for therapy services.
12. In Box 20, indicate the date treatment began for the given diagnosis, if treatment was initiated before this request.
13. Box 21 is for the total number of therapy sessions already rendered since the treatment plan was developed.
14. Document measurable short-term and long-term goals in Box 22, outlining functional achievements expected.
15. In Box 23, summarize the beneficiary's progress regarding the goals set in the treatment plan, including any education provided.
16. Indicate if the beneficiary is receiving school-based therapy services in Box 24.
17. List each unique HCPCS code/modifier in Box 25. Be diligent in ensuring each line corresponds accurately to the services provided.
18. Box 26 and 27 require procedure codes and necessary modifiers; reference the MDCH database for accurate information.
19. Specify the total number of service units requested in Box 28.
20. The attending physician must certify the request in Box 29, ensuring that they date and sign appropriately.
21. The therapist must also provide their certification and signature in Box 30—this step is crucial as unsigned requests will be returned.
22. Complete any additional boxes as required, knowing that some are reserved for MDCH use only.
23. Once all information is filled out, review the document thoroughly. You can then save changes, download, print, or share the completed form as necessary.

Act now to complete the MI MSA-115 form online for a smooth prior authorization request.