Get Mi Msa-1653-b 2018-2026

The MI MSA-1653-B is an essential form used for requesting prior authorization for special services through Medicaid. This guide provides you with a detailed overview of how to complete the form online, ensuring clarity and accuracy in your submission.

Follow the steps to effectively complete the MI MSA-1653-B online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. In Box 1, you will see a section labeled 'MDHHS Use Only.' Leave this box blank as it is reserved for internal use by the Michigan Department of Health and Human Services.
3. In Box 2, enter the provider’s name using the format of last name, first name, and middle initial.
4. Fill in Box 3 with the National Provider Identifier (NPI) number.
5. Provide the phone number in Box 4, ensuring it is correct for any follow-up communications.
6. Complete Box 5 with the provider's address, including number, street, suite (if applicable), city, state, and ZIP code.
7. Enter the fax number in Box 6 for document submission.
8. In Box 7, provide the beneficiary's name in the same format as Box 2.
9. Select the sex of the beneficiary in Box 8 by marking 'M' for male or 'F' for female.
10. Document the birth date of the beneficiary in Box 9.
11. Input the MIHealth card number for the beneficiary in Box 10.
12. In Box 11, enter the beneficiary's address, ensuring you include apartment or lot number if relevant.
13. For Box 12, indicate whether the beneficiary resides in a nursing facility by checking 'Yes' or 'No.' If 'Yes,' provide the facility's name, address, and phone number.
14. In Box 20, describe the item or service requested in detail, including manufacturer, model, and style.
15. For Box 21, enter the applicable HCPCS procedure code related to the requested service.
16. Input the appropriate HCPCS modifier in Box 22.
17. In Box 25, list the beneficiary's primary and secondary diagnoses. Include both the code and description.
18. Box 26 is for any additional remarks or insurance coverage information relevant to your request.
19. Box 28 must be completed, confirming provider certification that all necessary approvals have been understood.
20. Once all fields are completed accurately, save your changes. You can then download, print, or share the form as needed.

Start filling out the MI MSA-1653-B online today for a smooth and efficient process!