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MSA-0732. Private Duty Nursing Prior Approval - Request - michigan-2026
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How to use or fill out MSA-0732. Private Duty Nursing Prior Approval - Request - Michigan
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Prior Authorization Number, which is for MDHHS use only.
- Indicate whether this request is an initial or renewal by checking the appropriate box. If it's a renewal, specify if you are increasing or decreasing units.
- Fill in the PDN provider information, including agency name or individual’s name, NPI number, phone number, address, and fax number.
- Provide beneficiary information such as their full name, birth date, sex, mihealth card number, complete address, county, and primary diagnosis using the correct ICD code.
- If applicable, include other insurance details like company name and policy numbers.
- Complete hospital information if the beneficiary is currently hospitalized; include facility details and anticipated discharge date.
- List ordering physician information with their complete name, NPI number, contact details.
- Describe the services to be provided using HCPCS codes and indicate total units required per month along with start and end dates if known.
- Provide home environment details including siblings in the home and any other individuals requiring care.
- Ensure all signatures are completed at the end of the form to certify accuracy before submission.
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How long does it take to get approved for Medicaid in Michigan?
For commercial members only, please complete this form and submit via fax to 1-877- 325-5979. If you have any questions regarding this process, please contact BCBSM Provider Relations and Servicing or the Medical Drug Helpdesk at 1-800-437-3803 for assistance.
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