Get Mi Msa-115 2015

The MI MSA-115 form is an essential document for submitting a request for prior authorization of therapy services for Medicaid beneficiaries. This guide provides a clear, step-by-step approach to completing the form online, ensuring accuracy and compliance with requirements.

Follow the steps to complete the MI MSA-115 online effectively.

1. Click the ‘Get Form’ button to access the MI MSA-115 form and open it in the editor.
2. In box 2, enter the name of the Medicaid enrolled provider and in box 3, provide the National Provider Identifier (NPI). Make sure this information is accurate for identification.
3. Fill in box 4 to 6 with the provider’s telephone number, address, and fax number. Include area codes and ensure all details are correct.
4. In box 7 to 10, enter the beneficiary's name (last, first, middle initial), sex, mihealth card number, and birth date in MM/DD/YYYY format. Verify this information against the mihealth card.
5. Box 11 requires the date of the beneficiary's most recent hospital admission. Ensure this is up-to-date.
6. In box 12, include the diagnosis code(s) and description(s) pertinent to the requested service.
7. Complete box 13 with the date of onset of the beneficiary's condition, referencing exacerbations if applicable.
8. Fill boxes 14 to 16 with the therapist's name, office telephone number, and license/certification number.
9. In box 17, indicate whether this is an initial or continuing treatment authorization request.
10. Box 18 requires the date of the last prior authorization approval for the indicated diagnosis.
11. In box 19, note the calendar months during which treatment is to be provided, using a two-digit format.
12. Provide the treatment start date in box 20 if services have already begun.
13. Include the total number of sessions rendered since the development of the treatment plan in box 21.
14. In box 22, detail measurable treatment goals and the expected timeframe for achieving them.
15. Box 23 requires documentation of the beneficiary's progress in reference to the stated goals from the previous month.
16. Indicate in box 24 whether the beneficiary is receiving therapy services through a school-based program.
17. Complete lines in box 25 for each unique HCPCS code/modifier combination relevant to the request.
18. In box 26 and 27, refer to the MDHHS website for the covered HCPCS codes and required modifiers.
19. Specify in box 28 the total number of units requested during the treatment period.
20. Box 29 requires the attending physician’s certification, including their signature and date.
21. Lastly, box 30 requires the therapist’s certification by signing and dating the form. Unassigned requests will be returned.
22. Submit the completed form by mailing or faxing it to the MDHHS address provided in the instructions.

Start filling out your MI MSA-115 online to ensure timely approval for therapy services.