Get Mi Msa-0732 2015-2025

The MI MSA-0732 form is essential for requesting prior authorization for private duty nursing services for Medicaid beneficiaries. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently, ensuring a smooth submission process.

Follow the steps to successfully complete the MI MSA-0732 form online.

1. Click ‘Get Form’ button to access the MI MSA-0732 form and open it in your online editor.
2. Enter the prior authorization number, which is designated for MDHHS use. This number is important for tracking the request.
3. Indicate whether this is an initial request for services or a renewal. If it is a renewal, check the appropriate box to denote if there are any increases or decreases in units compared to the last authorization period.
4. Fill in the provider’s name. This can be the agency name or, if applicable, the name of an individual provider, including the designation of RN or LPN.
5. Provide the National Provider Identifier (NPI) number for the provider along with their contact details, including phone number, address, and fax number.
6. Complete the beneficiary information section by entering their full name, date of birth, sex, MIHealth card number, and their complete address.
7. If applicable, provide details regarding other insurance the beneficiary may have, including the insurance company name and policy numbers.
8. Fill out hospital information if the beneficiary is currently hospitalized. This should include the hospital name, full address, phone number, and discharge planner details.
9. Provide the ordering physician's information, including name, NPI number, contact details, and address.
10. Describe the services to be provided, including HCPCS codes, total units required per month, and the anticipated start and end dates for the services.
11. Include home environment information, noting the number of siblings and other individuals in the home needing care. Mention the names of caregivers and whether they work or attend school.
12. If applicable, provide current school information for the beneficiary, including the number of hours attended per day and week.
13. Document if more than one private duty nursing agency is involved, along with necessary names and contact details.
14. List any other services being provided in the home, as this may affect the request.
15. Upon completing all sections, sign the form to certify the accuracy of the information provided. Ensure the parent or guardian signs as well, if necessary.
16. Submit the completed MI MSA-0732 form and any required documentation via mail or fax, as instructed.

Start filling out your MI MSA-0732 form online today to request the necessary services.