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How to fill out the MI MSA-115 online
The MI MSA-115 form is essential for Medicaid enrolled outpatient providers seeking prior authorization for therapy services. This guide provides clear, step-by-step instructions to ensure accurate completion of the form online, enabling efficient processing of therapy service requests.
Follow the steps to complete the MI MSA-115 form online effectively.
- Press the ‘Get Form’ button to acquire the MI MSA-115 form and display it in the online editor.
- Begin by filling in the provider details. Include the provider’s name and National Provider Identifier (NPI) in Boxes 2 and 3.
- In Boxes 4 to 6, input the provider’s contact information: telephone number, physical address, and fax number.
- Next, complete Boxes 7 to 10 with the beneficiary’s name, sex, mihealth card number, and birth date. Verify this information from the beneficiary's mihealth card.
- Indicate the date of the beneficiary's most recent hospital admission in Box 11.
- In Box 12, enter the relevant ICD-9-CM diagnosis code(s) and corresponding description(s). This should relate directly to the requested service.
- Complete Box 13 with the date of onset and any exacerbation details if applicable.
- Provide the therapist’s name, office telephone number, and license/certification number in Boxes 14 to 16.
- Select the type of request in Box 17 by marking 'Initial' for a new request or 'Continuing' for ongoing treatment authorization.
- Document goals for the therapy in Box 22, ensuring they are measurable and include expectations for the beneficiary’s progress.
- Summarize the beneficiary's progress in Box 23, referencing previous documentation and including discharge plans if relevant.
- Indicate if therapy services are provided through a school-based program in Box 24.
- Fill out Boxes 25 to 27 by providing unique HCPCS codes, required modifiers, and anticipated service units.
- In Box 29, the attending physician must sign to certify the request, indicating if this is an initial or re-certification.
- Ensure the therapist's signature is entered in Box 30, as authorization is mandatory for processing the request.
- Finally, review all entries for accuracy, and prepare to save or send the completed form via specified submission methods.
Complete your MI MSA-115 form online today for streamlined processing of therapy service requests.
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To apply for Medicaid in Michigan under the MI MSA-115, you will need several key documents. These typically include proof of income, identification, residency verification, and any medical records pertinent to your application. Gathering these documents ahead of time can expedite your application process. For additional assistance on how to prepare these documents, platforms like US Legal Forms offer valuable resources.
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