Msa 115 Form PDF Details

Are you aware of the MSA 115-to put it simply, a Medical Savings Account (MSA) is an IRS approved plan that allows individuals to save for and pay qualified medical expenses on a tax-free basis. This type of account allows you to use pre-tax dollars to pay for healthcare such as doctor’s visits or medication. The MSA 115 form must be used by claimants filing taxes with their Federal income tax return - if they are eligible and have had an MSA opened and contributed funds within the year in which they were claiming said expenses. In this blog post, we will provide helpful information about how to fill out this form correctly & efficiently along with tips on determining your eligibility criteria as well as best practices when making contributions/distributions from your account! Read on to learn more!

QuestionAnswer
Form NameMsa 115 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmsa 115 word document, michigan physical authorization form, msa 115 pdf, michigan msa 115

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Michigan Department of Health and Human Services

Completion Instructions for MSA-115

Occupational Therapy - Physical Therapy - Speech Therapy

Prior Approval Request/Authorization

General Instructions

The MSA-115 must be used by Medicaid-enrolled outpatient hospitals, outpatient therapy providers, nursing facilities and home health agencies to request prior authorization (PA) for therapy services. MDHHS requires that the MSA-115 be typewritten, handwritten forms will not be accepted. Fill-in enabled copies of this form can be downloaded from the Michigan Department of Health and Human Services (MDHHS) website www.michigan.gov/medicaidproviders >> Policy, Letters & Forms. The PA request must be complete and of adequate clarity to permit a determination of the appropriateness of the service without examination of the beneficiary.

PA may be authorized for a period not to exceed six months for outpatient therapy providers and outpatient hospitals, or two months for home health agencies and nursing facilities. If continued treatment is necessary, a subsequent request for PA must be submitted. The provider should retain a copy of the PA form until the approval or denial is determination is received.

For complete information on covered services, PA, and documentation requirements, refer to the Therapy Services Chapter of the Michigan Medicaid Provider Manual located at the MDHHS website www.michigan.gov/medicaidproviders >> Policy, Letters & Forms >> Medicaid Provider Manual.

Attachments/Additional Documentation

All additional attachments/documentation submitted with the request must contain the beneficiary name and mihealth card number, provider name and address, and the provider’s National Provider Identifier (NPI) number.

When requesting the initial PA, the provider must attach a copy of the initial evaluation and treatment plan to the PA request.

Form Completion

The following fields must be completed unless stated otherwise:

 

Box Number(s)

 

Instructions

 

 

 

Box 1

 

MDHHS use only.

 

 

 

 

 

Box 2 - 3

 

The Medicaid enrolled provider’s name and NPI.

 

 

 

 

 

Box 4 - 6

 

The provider’s telephone number (including area code), address and fax number (including

 

 

 

area code).

 

 

 

 

 

Box 7- 10

 

The beneficiary’s name (last, first, and middle initial), sex, mihealth card number, and birth

 

 

 

date (in the eight-digit format: MM/DD/YYYY). The information should be taken directly

 

 

 

from the mihealth card and should be verified through the Community Health Automated

 

 

 

Medicaid Processing System (CHAMPS) (Eligibility Inquiry and/or 270/271 transaction).

 

 

 

 

 

Box 11

 

The date the beneficiary was most recently admitted to the hospital or facility.

 

 

 

 

 

Box 12

 

Enter the beneficiary's diagnosis(es) code(s) and description(s) that relate to the service

 

 

 

being requested.

 

 

 

 

 

Box 13

 

The date of onset must be entered. The approximate date of exacerbation must be cited if

 

 

 

the beneficiary has a chronic disease (e.g., arthritis) and recently suffered such

 

 

 

exacerbation.

 

 

 

 

 

Box 14 -16

 

The therapist’s name, office telephone number (including area code), and applicable

 

 

 

license/certification number.

 

 

 

 

 

Box 17

 

Initial: The treatment authorization request is the initial prior authorization request for the

 

 

 

beneficiary under this treatment plan. Continuing: The treatment authorization request is

 

 

 

to continue treatment for additional calendar month(s) of service under the treatment plan.

 

 

 

 

 

Box 18

 

The date MDHHS approved the last approved prior authorization request for the given

 

 

 

diagnosis.

 

 

 

 

 

Box 19

 

The requested date range for which treatment is to be rendered, in a eight-digit format (e.g

 

 

 

mm/dd/yyyy to mm/dd/yyyy).

 

 

 

 

MSA-115 (8/18) Previous editions are obsolete.

Page 1 of 3

 

Box Number(s)

 

Instructions

 

 

 

Box 20

 

The date treatment was started for the given diagnosis (if treatment was initiated

 

 

 

previously).

 

 

 

 

 

Box 21

 

The total number of sessions rendered since the development of the treatment plan.

 

 

 

 

 

Box 22

 

Goals must be measurable. In functional terms, the provider’s expectation for the

 

 

 

beneficiary’s ultimate achievement and the length of time it will take (e.g., ambulation

 

 

 

unassisted for 20 feet; able to dress self within 15 minutes; oral expression using 4-5 word

 

 

 

phrases to express daily needs). See Medicaid Provider Manual for additional

 

 

 

documentation requirements.

 

 

 

 

 

Box 23

 

Documentation of the beneficiary’s progress from the prior period to the current time in

 

 

 

reference to the measurable and functional goals stated in the treatment plan.

 

 

 

Documentation of the beneficiary's nursing and family education may be included. The final

 

 

 

month of anticipated treatment should include the discharge plan for the carry-over of

 

 

achieved goals to supportive personnel. See Medicaid Provider Manual for additional

 

 

 

documentation requirements.

 

 

 

 

 

Box 24

 

Indicate if the beneficiary is receiving therapy services through school-based services

 

 

 

program.

 

 

 

 

 

Box 25

 

Indicate the treatment plan frequency (e.g., 1x/week, 3x/week, 1x/month, etc.) and duration

 

 

 

per visit in 15-minute increments, i.e., units (e.g. 2 units/visit, 4 units/visit, etc.).

 

 

 

 

 

Box 26

 

Complete a separate line for each unique HCPCS code/modifiers combination.

 

 

 

 

 

Box 27

 

The Therapies Database on the MDHHS website lists the HCPCS codes that describe

 

 

 

covered services. The database is located at the MDHHS website

 

 

 

www.michigan.gov/medicaidproviders >> Billing and Reimbursement >> Provider Specific

 

 

 

Information.

 

 

 

 

 

Box 28

 

The Billing & Reimbursement Chapter in the Medicaid Provider Manual list the required

 

 

 

modifiers used to describe covered services for therapy providers. The Medicaid Provider

 

 

Manual is located at the MDHHS website www.michigan.gov/medicaidproviders >> Policy,

 

 

 

Letters, & Forms >> Medicaid Provider Manual.

 

 

 

 

 

Box 29

 

The total number of units the service is to be provided during the requested treatment

 

 

 

period.

 

 

 

 

 

Box 30

 

The authorized prescribing practitioner must indicate if this is an initial certification or a re-

 

 

 

certification and sign and date. Signature is required each time a request is made.

 

 

 

 

 

Box 31

 

The therapist certification is the signature of an authorized representative. The business

 

 

 

office of a hospital may designate the director of the department providing the service as its

 

 

 

representative. All unsigned requests will be returned for signature.

 

 

 

 

 

Box 32-35

 

MDHHS use only.

 

 

 

 

Form Submission:

PA request forms for all eligible Medicaid beneficiaries must be submitted electronically*, mailed or faxed to:

MDHHS – Program Review Division

P.O. Box 30170

Lansing, Michigan 48909

Fax Number: (517) 335-0075

If submitting electronically, the completed MSA-115 must be uploaded along with the supporting clinical documentation required.

To check the status of a PA request, contact the Program Review Division via telephone at 1-800-622-0276 or electronically via the CHAMPS Provider Portal located at https://milogintp.michigan.gov.

Authority: Title XIX of the Social Security Act.

Completion: Is voluntary but is required if payment from applicable programs is sought.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs, or disability.

MSA-115 (8/18) Previous editions are obsolete.

Page 2 of 3

MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES

OCCUPATIONAL THERAPY - PHYSICAL THERAPY –

SPEECH THERAPY

PRIOR APPROVAL REQUEST/AUTHORIZATION

1. PRIOR AUTHORIZATION NUMBER (MDHHS USE ONLY)

The provider is responsible for eligibility verification. Approval does not guarantee beneficiary eligibility or payment.

All fields must be completed and typewritten.

2. TREATMENT SITE (Medicaid enrolled provider's name)

3. PROVIDER NPI NUMBER

4. PHONE NUMBER

5. ADDRESS (NUMBER, STREET, STE., CITY, STATE, ZIP)

6. FAX NUMBER

7. BENEFICIARY NAME (LAST, FIRST, MIDDLE INITIAL)

 

8. SEX

 

9. MIHEALTH CARD NUMBER

10. BIRTH DATE

11. ADM. DATE

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

12. ICD DIAGNOSIS(ES) CODE(S) AND DESCRIPTION(S) TO BE TREATED/EVALUATED

 

 

 

 

 

13. ONSET DATE

 

 

 

 

 

 

14. THERAPIST NAME (LAST, FIRST, MIDDLE INITIAL)

 

15. OFFICE PHONE NUMBER

16. LICENSE/CERTIFICATION NUMBER

 

 

 

 

 

 

17. TREATMENT AUTHORIZATION REQUEST

18. LAST AUTHORIZATION

19. TREATMENT MONTHS

20. DATE STARTED

21. # PREV. SESSIONS

INITIAL

CONTINUING

 

/ /

to / /

 

 

 

 

 

 

 

22. GOALS (NOTE: SEE MEDICAID PROVIDER MANUAL FOR ADDITIONAL DOCUMENTATION REQUIREMENTS.)

 

 

 

SHORT TERM GOALS

 

 

 

LONG TERM GOALS

 

23. PROGRESS SUMMARY (NOTE: SEE MEDICAID PROVIDER MANUAL )

24. SCHOOL THERAPY PROGRAMS

 

25. TREATMENT REQUESTED

 

30. PHYSICIAN CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

FREQUENCY:

 

 

I certify

re-certify

that I have examined the patient named above and

 

 

 

 

DURATION VISIT:

(UNITS)

 

have determined that skilled therapy is necessary; that services will be

26.

 

27.

28.

 

29.

 

furnished on an in-patient and/or out-patient basis while the patient is under

LINE NO.

 

PROCEDURE CODE

MODIFIER

 

TOTAL UNITS PER PA

 

my care; that I approve the above treatment goals and will review every 60

01

 

 

 

 

 

 

 

days or more frequently if the patient’s condition requires.

 

 

02

 

 

 

 

 

 

 

 

 

 

 

 

03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESCRIBING PRACTITIONER’S NAME (TYPE OR PRINT)

 

 

04

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRESCRIBING PRACTITIONER’S SIGNATURE

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

MDHHS USE ONLY

 

 

31. THERAPIST CERTIFICATION

 

 

 

 

 

 

 

 

 

 

The patient named above (parent or guardian if applicable) understands the

32. REVIEW ACTION:

 

33. AUTHORIZATION PERIOD APPROVED

 

 

 

necessity to request prior approval for the services indicated. I understand

APPROVED

 

 

 

 

 

 

 

 

 

 

that services requested herein require prior approval and, if approved and

RETURNED

 

 

 

 

 

 

 

 

 

 

submitted on the appropriate invoice, payment and satisfaction of approved

DENIED

 

 

 

 

 

 

 

 

 

 

 

 

services will be from Federal and State funds. I understand that any false

NO ACTION

 

 

 

 

 

 

 

 

 

 

claims, statements or documents or concealment of a material fact may lead

APPROVED AS AMENDED

 

 

 

 

 

 

 

 

 

 

to prosecution under applicable Federal or State law.

 

 

 

 

 

 

 

 

 

 

 

 

34. CONSULTANT REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

See CHAMPS

 

 

 

 

 

__________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THERAPIST’S SIGNATURE

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35. CONSULTANT SIGNATURE

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

MSA-115 (8/18) Previous editions are obsolete.

Page 3 of 3

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michigan physical therapy prior authorization completion process explained (step 1)

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