AUTHORITY Title V and Title XIX of the Social Security Act. COMPLETION Is voluntary. DCH-0078 12-14 Previous editions are obsolete. Michigan Department of Community Health Completion Instructions for DCH-0078 Request to Add Terminate or Change Other Insurance Form DCH-0078 is a formal request for change in other insurance status and must be submitted by the Medicaid provider Medicaid Health Plan Local Health Department or the Department of Human .
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How to fill out the MI DCH-0078 online
The MI DCH-0078 form is an essential document for requesting changes to other insurance coverage, submitted to the Michigan Department of Health and Human Services. This guide will provide you with clear instructions on how to complete the form online, ensuring your requests are accurately processed.
Follow the steps to properly complete the MI DCH-0078 form online.
- Click the ‘Get Form’ button to obtain the MI DCH-0078 document and open it in an online editor.
- In Section 1, select the appropriate request type by checking the box next to 'Add', 'Terminate', or 'Change'. This indicates what action you want to take regarding insurance.
- Move to Section 2 to provide Medicaid provider, Medicaid Health Plan, local health department, or MDHHS caseworker information. Fill in your full name, county/local health department, date, phone number, fax number, and case number, if available.
- Proceed to Section 3. List the beneficiaries or clients you wish to add, terminate, or change insurance for. For each beneficiary or client, provide their name, date of birth, and miHealth ID. Ensure that you include all relevant individuals.
- In Section 4, fill out the policyholder information. Include the name (last, first, middle), date of birth, social security number, employer name, and employer city and state. Also, select the type of coverage from the options, and provide the names of health, pharmacy, dental, and vision insurance companies, along with their respective group/policy and certificate/contract numbers.
- In Section 5, indicate the reason for the change. Select from options such as divorce, coverage termination, military discharge, or employment termination. If 'Other' is selected, provide a brief explanation and the date of the change.
- Attach any supporting documentation needed to justify your request. This may include letters from insurance companies or employers.
- Review all information you have entered for accuracy. Ensure any required fields are completed.
- Once you have completed the form, save your changes. You can then download, print, or share the form as needed. Make sure to keep a copy for your records.
- Submit the form through the appropriate channels as indicated in the instructions, either via fax or mail.
Start filling out your MI DCH-0078 form online today!
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How do I speak to someone at Michigan Medicaid?
Tell you which doctors, pharmacies and hospitals are part of each Medicaid health plan. Answer general questions you may have about Medicaid benefits. Enroll you in the Medicaid Health Plan you choose. For more information, call Michigan ENROLLS at 1-888-367-6557.
What is a prior authorization for Michigan Medicaid drugs?
A Michigan Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug prescription in the state of Michigan. In this form, the physician provides their clinical reasoning for making this request instead of prescribing a drug from the Preferred Drug List (PDL).
Should I call my insurance for prior authorization?
If you think your drug may require a prior authorization, call your insurer directly to confirm.
How do I cancel my MI bridges benefits online?
To add, terminate or change other insurance on-line, visit https://.Michigan.gov/ReportTPL to access the form and instructions. Allow 7-10 business days for the request to be completed.
What is the phone number for Medicaid prior authorization in Michigan?
Then, select the Prior Authorization and Notification tool on your Link dashboard. Or, call 888-397-8129.
Does Michigan Medicaid require prior authorization?
Medicaid requires prior authorization (PA) to cover certain services before those services are rendered to the beneficiary. The purpose of PA is to review the medical need for certain services. It does not serve as an authorization of fees or beneficiary eligibility.
How do I change my name with Medicaid Michigan?
Please contact your MDHHS caseworker if your name and/or address have changed. Report NAME CHANGES and ADDRESS CHANGES to your MDHHS caseworker. A mihealth card can not be issued until these changes are reported to your MDHHS worker.
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