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Michigan approval authorization form 2026

The document outlines the procedures for submitting a Dental Prior Approval Authorization Request (MSA-1680-B) for Medicaid beneficiaries and those enrolled in Children's Special Health Care Services in Michigan. It details who should complete the form, the approval process, requirements for extensions, and specific instructions for orthodontic services. Additionally, it provides contact information for further inquiries and emphasizes the importance of prior approval for dental services.

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Click ‘Get Form’ to open it in our editor.
Begin by filling in the provider's information, including name, address, and contact details. Ensure accuracy as this will be used for communication regarding the authorization.
Next, enter the beneficiary's details such as name, birth date, and MI Health Card Number. This information is crucial for identifying the patient.
Indicate whether the patient lives in a nursing home and if they are covered by any other dental plan. This helps determine eligibility for services.
Complete the sections regarding CSHCS diagnosis codes and descriptions. If applicable, provide details about x-rays and orthodontic treatments.
Finally, review all entries for completeness and accuracy before signing the form. Your signature certifies that you understand the necessity of prior approval.

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