Get Mi Msa-1653-b 2015

This guide aims to assist users in completing the MI MSA-1653-B form efficiently. The form is essential for Medicaid providers to request prior authorization for special services. Follow this straightforward guide to ensure your submission is accurate and complete.

Follow the steps to successfully fill out the MI MSA-1653-B online.

1. Press the ‘Get Form’ button to access and open the MI MSA-1653-B form online.
2. Begin by completing Box 1, titled 'Prior Authorization Number', which is designated for MDHHS use only. Do not fill this out as it will be completed by the department.
3. In Box 2, enter the provider's name, ensuring you include the last name, first name, and middle initial.
4. Input your National Provider Identifier (NPI) number in Box 3.
5. Provide a valid phone number in Box 4.
6. Complete Box 5 with the provider's address, including the number, street, suite, city, state, and ZIP code.
7. Fill in your fax number in Box 6.
8. In Box 7, enter the beneficiary's name, following the format of last name, first name, and middle initial.
9. Indicate the beneficiary's sex in Box 8 by selecting 'M' for male or 'F' for female.
10. In Box 9, input the beneficiary's birth date.
11. Provide the MIHealth card number in Box 10.
12. In Box 11, enter the beneficiary's address, including the number, street, apartment or lot number, city, state, and ZIP code.
13. Address Box 12 by selecting 'Yes' if the beneficiary resides in a nursing facility; include the facility's name, address, and phone number if applicable. Select 'No' otherwise.
14. Fill in Box 13 with the referring or ordering physician's name.
15. Enter the NPI number of the referring physician in Box 14.
16. Provide a contact number for the referring physician in Box 15.
17. Complete Box 16 with the referring physician's address.
18. List all relevant details in Box 19. Include a complete description of the requested item, ensuring to specify the brand name, model, and catalog or part number, as necessary.
19. Enter the applicable HCPCS procedure code in Box 20.
20. In Box 21, enter the relevant HCPCS modifier.
21. Complete Box 24 with the beneficiary's primary and secondary diagnoses, providing both the code and description.
22. Provide any additional remarks in Box 25, including the verbal authorization date or retroactive services if applicable.
23. Indicate any other services provided to the beneficiary during the past year in Box 26.
24. Box 27 requires provider certification. Ensure the provider’s signature and date are included to confirm understanding of the prior approval process.
25. Once all sections are completed, save any changes. You can download, print, or share the form as necessary.

Complete your MI MSA-1653-B form online today to ensure a smooth submission process.