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 Msa 1680 B 2014-2025

Msa 2014-2025 Form

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What is the MSA 1904?

The MSA 1904 is a specific form used in the context of Michigan's Medicaid program. It serves as a prior authorization request for dental services, ensuring that necessary treatments are approved before they are provided. This form is critical for both healthcare providers and patients, as it helps streamline the approval process for dental services that may require additional scrutiny or justification under Medicaid guidelines.

Steps to Complete the MSA 1904

Completing the MSA 1904 requires careful attention to detail to ensure that all necessary information is accurately provided. Here are the key steps:

  • Begin by gathering all relevant patient information, including their Medicaid identification number and personal details.
  • Clearly indicate the specific dental services being requested, including codes and descriptions as necessary.
  • Provide clinical justification for the requested services, detailing why they are medically necessary.
  • Ensure that all required signatures are obtained from both the provider and the patient, as applicable.
  • Review the completed form for accuracy and completeness before submission.

How to Obtain the MSA 1904

The MSA 1904 form can be obtained through various channels. It is typically available on the Michigan Department of Health and Human Services website or through dental offices that participate in the Medicaid program. Providers may also request copies directly from Medicaid representatives if needed. It is important to ensure that you are using the most current version of the form to avoid any processing delays.

Legal Use of the MSA 1904

The MSA 1904 must be used in accordance with state and federal regulations governing Medicaid services. This includes ensuring that the services requested are covered under the Medicaid program and that all documentation is submitted in compliance with the Michigan Medicaid policies. Misuse of the form, such as submitting false information or requesting services that are not medically necessary, can lead to penalties and denial of claims.

Key Elements of the MSA 1904

Several key elements are essential for the MSA 1904 to be considered valid. These include:

  • Patient Information: Accurate details about the patient, including name, Medicaid number, and date of birth.
  • Provider Information: Information about the dental provider submitting the request, including their Medicaid provider number.
  • Service Details: A clear description of the dental services being requested, including any relevant codes.
  • Clinical Justification: A detailed explanation of why the requested services are necessary for the patient's health.
  • Signatures: Required signatures from both the provider and the patient, confirming the accuracy of the information provided.

Form Submission Methods

The MSA 1904 can be submitted through multiple channels to ensure timely processing. Common submission methods include:

  • Online Submission: Many providers may have access to online portals that allow for electronic submission of the MSA 1904.
  • Mail: The completed form can be mailed directly to the appropriate Medicaid office, ensuring that it is sent to the correct address.
  • In-Person Submission: Providers may also choose to deliver the form in person at designated Medicaid offices to expedite processing.

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