Get Ma 563

Completing the MA 563 form online is a crucial step for requesting a 180-day exception. This guide will provide you with detailed instructions to help you navigate each section of the form with confidence.

Follow the steps to fill out the MA 563 with ease.

1. Click ‘Get Form’ button to obtain the MA 563 form and open it in your browser for editing.
2. In Item 1, enter the provider’s name in the designated field.
3. For Item 2, input the thirteen-digit MA ID number assigned to the provider.
4. In Item 3, enter the name of the beneficiary.
5. For inpatient services in Item 4, provide the discharge date; for outpatient services, enter the date of service.
6. If applicable, in Item 5, enter the date the application was mailed to the county assistance office (CAO) and ensure to attach the required documentation.
7. In Item 6, if applicable, enter the process date of the PA 162 Notice of Eligibility form and attach a copy of this form.
8. For Item 7, enter the date the payment request was mailed to the third party and include the necessary documentation.
9. In Item 8, provide the process date of the third party statement/explanation of benefits (EOB) and attach a copy.
10. If applicable, for Item 9, enter the date the Prior Authorization was processed and attach the notification letter.
11. In Item 10, if applicable, enter the date the Program Exception was processed and include the notification letter.
12. In Item 11, if your claim was previously submitted, enter the date the MA invoice was mailed to the Department of Human Services.
13. For Item 12, check the block that describes the reason for requesting an exception.
14. In Item 13, the responsible person must sign and date the form.
15. For Item 14, enter the telephone number of the person whose signature appears in Item 13.
16. Finally, review the completed form for accuracy, then save changes, download, print, or share the form as needed.

Complete your MA 563 form online today to ensure your request is processed efficiently.