For beneficiaries enrolled in Medicaid Health Plans, other managed care plans, or Healthy Kids Dental, providers must contact the assigned plan for authorization requirements.
Fax: providers may submit PA requests via fax to (517) 335-0075.
Documents: all documents must contain the beneficiary name and mihealth card number.
Standard reviews: standard reviews will be determined within 7 calendar days.
| Question | Answer |
|---|---|
| Form Name | MSA-115 |
| Form Length | 5 pages |
| Fillable? | Yes |
| Fillable fields | 83 |
| Avg. time to fill out | 14 min |
| Edition | 3/2026 |
| Issuing agency | Michigan Department of Health and Human Services |
| Other names | MSA-115, MSA 115, Form 115, MSA115, Michigan therapy prior authorization request, MDHHS MSA-115 |
| Official source | MSA-115 (Rev 3/2026), Michigan Department of Health and Human Services |
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