Msa115 form 2009-2025

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308 votes

The document outlines the completion instructions for the MSA-115 form, which is used by Medicaid enrolled providers in Michigan to request prior authorization for occupational, physical, and speech therapy services. It details the necessary information required on the form, including beneficiary and provider details, treatment goals, and documentation requirements. The document emphasizes the importance of clarity and completeness in requests to facilitate processing and specifies the time limits for authorized therapy services.

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Click ‘Get Form’ to open the msa115 form 2009 in the editor.
Begin by filling out Box 2-3 with the Medicaid enrolled provider’s name and National Provider Identifier (NPI). Ensure accuracy for smooth processing.
In Box 4-6, enter the provider’s telephone number, address, and fax number. This information is crucial for communication regarding the authorization request.
Complete Boxes 7-10 with the beneficiary’s details: name, sex, mihealth card number, and birth date. Verify this information against the mihealth card for correctness.
Proceed to Box 12 to input the diagnosis code(s) related to the requested service. This should align with your treatment plan.
Fill in Boxes 22 and 23 with measurable goals and a progress summary. Clearly outline expected achievements and document any advancements since the last session.
Finally, ensure that all required signatures are obtained in Boxes 29 and 30 before submitting your completed form via mail or fax as instructed.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (105 Votes)
2015	4 Satisfied (30 Votes)
2012	4.4 Satisfied (308 Votes)
2009	4.2 Satisfied (60 Votes)

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