Get Mi Msa-0732 2018-2025

The MI MSA-0732 form is essential for requesting prior authorization for private duty nursing services under Medicaid for beneficiaries under 21 years of age. This guide provides step-by-step instructions on how to accurately fill out the form online, ensuring a seamless submission process.

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

1. Begin by pressing the ‘Get Form’ button to access the MI MSA-0732 form, which you will open in your online editor.
2. In the first box, input the prior authorization number, which is specifically for MDHHS use.
3. Indicate whether this request is an initial authorization or a renewal by selecting the appropriate checkbox. If renewing, specify if you are increasing or decreasing the units.
4. Fill in the provider’s name, providing either the complete agency name or the name of the individual RN or LPN. Be sure to include their NPI number, phone number, address, and fax number.
5. Enter the beneficiary's information, including their full name, birth date, sex, MI health card number, complete address, county, and the primary diagnosis using the correct ICD code.
6. If applicable, provide details of any additional health insurance, including the name of the insurance company, group/policy number, and certificate/contract number.
7. Complete the hospital information section with the hospital's name, address, phone number, anticipated discharge date, and the name and contact information of the discharge planner if the beneficiary is hospitalized.
8. Provide the ordering physician's name (including MD or DO), their NPI number, and their contact information.
9. Describe the services to be provided, using the appropriate HCPCS code and modifiers as required. Include the total number of units needed per month along with the start and end dates of service.
10. Fill in the home environment information, noting the number of siblings in the home, any additional individuals requiring care, and details about caregivers.
11. If applicable, provide information regarding the beneficiary's current school attendance, including hours per day and week.
12. If there is more than one PDN or agency involved, list their names and contact details, and indicate which PDN will manage the care plan.
13. Disclosure of other services in the home is required. Failing to do so may impact Medicaid reimbursement.
14. Both the provider and the parent or guardian must sign and date the certification fields to confirm the accuracy and completeness of the information provided.
15. Finally, save your changes to the form. You can download, print, or share the completed MI MSA-0732 form as required.

Complete your MI MSA-0732 form online today to ensure timely processing and approval.