Msa 1680 b 2012 form-2026

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The document outlines the procedures for submitting a Dental Prior Authorization Request (MSA-1680-B) for Medicaid beneficiaries and those enrolled in Children's Special Health Care Services in Michigan. It details the completion process, submission guidelines, and requirements for dental providers, including necessary documentation and timelines for service approval.

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Click ‘Get Form’ to open the MSA-1680-B in our editor.
Begin by filling in the provider's information, including name, address, and contact details. Ensure accuracy as this information is crucial for processing.
Next, enter the beneficiary's details such as name, birth date, and MI Health Card number. This section is vital 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 CSHCS diagnosis section with appropriate ICD codes and descriptions. This is essential for authorization of specific treatments.
If applicable, indicate if x-rays are enclosed and provide treatment plans for orthodontics or prosthesis placements.
Finally, review all entries for completeness and accuracy before signing the certification at the bottom of the form.

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