Instructions for msa-115 Occupational Therapy Physical Therapy




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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 requests that the MSA-115 be typewritten to facilitate processing. 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 and Forms >> Forms. The request for PA 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 three 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 returned.

For complete information on covered services and PA requirements, refer to the Hospital, Outpatient Therapies, Nursing Facility or Home Health Chapters of the Michigan Medicaid Provider Manual.


Attachments/Additional Documentation


Any additional documentation submitted with the request must contain the beneficiary name and mihealth card number, provider name and address, and the provider’s NPI number.

When requesting the initial PA, the provider must attach a copy of the initial evaluation and written 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 National Provider Identifier (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 this treatment plan.

Box 18

The date MDHHS signed the last approved prior authorization request for the given diagnosis.

Box 19

The calendar months in which treatment is to be rendered, in a two-digit format (e.g., April should be shown as 04, April - May should be shown as 04, 05).

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 this 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 month 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.

Box 24

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

Box 25

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

Box 26

The Outpatient Therapy and Home Health Databases on the MDHHS website list 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 27

The Outpatient Therapy Database on the MDHHS website lists the required modifiers used to describe covered services for outpatient hospital and nursing care facility providers. The database is located at the MDHHS website www.michigan.gov/medicaidproviders >> Billing and Reimbursement >> Provider Specific Information.

Box 28

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

Box 29

The attending physician must indicate if this is an initial certification or a re-certification and sign and date. The attending physician’s signature is required each time a request is made.

Box 30

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 31-34

MDHHS use only.

Form Submission


PA request forms for all eligible Medicaid beneficiaries must be mailed or faxed to:

MDHHS - Medical Services Administration

Program Review Division

P.O. Box 30170

Lansing, Michigan 48909

Fax Number: (517) 335-0075



To check the status of a PA request, contact the MDHHS - Medical Services Administration, Program Review Division via telephone at 1-800-622-0276.

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

 INITIAL CONTINUING


18. LAST AUTHORIZATION

     


19. TREATMENT MONTHS

     


20. DATE STARTED

     


21. # PREV. SESSIONS

   


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

 YES  NO



29. PHYSICIAN CERTIFICATION

I certify  re-certify  that I have examined the patient named above and have determined that skilled therapy is necessary; that services will be furnished on an in-patient and/or out-patient basis while the patient is under my care; that I approve the above treatment goals and will review every 30 days or more frequently if the patient’s condition requires.


     

PHYSICIAN NAME (TYPE OR PRINT)


PHYSICIAN SIGNATURE DATE



25.

LINE NO.


26.

PROCEDURE CODE



27.

MODIFIER


28.

TOTAL UNITS PER PA



01

     

  

     

02

     

  

     

03

     

  

     

04

     

  

     

05

     

  

     

MDHHS USE ONLY

30. THERAPIST certification

The patient named above (parent or guardian if applicable) understands the necessity to request prior approval for the services indicated. I understand that services requested herein require prior approval and, if approved and submitted on the appropriate invoice, payment and satisfaction of approved services will be from Federal and State funds. I understand that any false claims, statements or documents or concealment of a material fact may lead to prosecution under applicable Federal or State law.

THERAPIST SIGNATURE DATE


31. REVIEW ACTION:

APPROVED 

INSUFFICIENT DATA 

DENIED 


NO ACTION 

APPROVED AS AMENDED 



32. TREATMENT MONTHS APPROVED


33. CONSULTANT REMARKS


34. CONSULTANT SIGNATURE DATE



AUTHORITY: Title XIX of the Social Security Act. The Michigan Department of Community Health is an equal



COMPLETION: Is Voluntary, but is required if payment from applicable programs is sought. opportunity employer, services and programs provider.
MSA-115 (11/12) Previous editions are obsolete. Page of


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