ࡱ>  bjbj |}g}g$PLH4 6&|" " " " V!8#4$4444444$F8:5b'V!V!b'b'5" " 45~-~-~-b'F" " 4~-b'4~-~-/C0" = =7*'j0450 60,;(;C0C0;W0^%Z%@~-%4,&6^%^%^%55*^%^%^% 6b'b'b'b';^%^%^%^%^%^%^%^%^%X N: MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES DENTAL PRIOR APPROVAL AUTHORIZATION REQUEST Instructions for MSA-1680-B The Dental Prior Approval Authorization Request form (MSA-1680-B) is to be used for persons with Medicaid coverage in the Fee-for-Service dental benefit and persons enrolled in Childrens Special Health Care Services (CSHCS). For beneficiaries enrolled in Healthy Kids Dental, Healthy Michigan Plan Health Plans, Integrated Care Organizations and pregnant women enrolled in a Medicaid Health Plan, providers should contact the assigned plan for authorization requirements. The MSA-1680-B must be completed by private dentists or community-based dental clinics (e.g., local health departments, Federally Qualified Health Centers (FQHC)). MDHHS requires that the MSA-1680-B be typewritten; handwritten forms will not be accepted. The status of a prior authorization request may be reviewed in CHAMPS. Additionally, providers will receive a prior authorization determination letter. Approved services are required to be completed before the end of the prior authorization. To request an extension, the provider must submit a copy of the determination letter and required documentation within 15 days prior to the end date of the current authorization. If the original prior authorization is over one year old, a new prior authorization request must be submitted. For further information on the prior authorization of dental services, refer to the Prior Authorization Section, Dental Chapter of the Medicaid Provider Manual. Dental providers treating CSHCS beneficiaries are required to submit the beneficiarys CSHCS qualifying diagnosis related to the services being requested. For authorization of orthodontics and/or crown and bridge services for beneficiaries enrolled in CSHCS, refer to the Childrens Special Health Care Services Dental Benefits Section, Dental Chapter of the Medicaid Provider Manual. The completed MSA-1680-B may be mailed, faxed, or submitted via CHAMPS, depending on whether radiograph films are necessary, to: Michigan Department of Health and Human Services Dental Prior Authorization P.O. Box 30154 Lansing, MI 48909 Fax: (517) 335-0075 All change requests to an approved prior authorization should be faxed to 517-241-7813. Questions should be directed to Program Review Division at 1-800-622-0276. If submitting electronically, the completed MSA-1680-B and all radiographs must be attached, as required by policy. Radiographs will only be returned upon request, as indicated in box 17. Michigan Department of Health and Human Services DENTAL PRIOR APPROVAL AUTHORIZATION REQUEST  HYPERLINK "http://www.michigan.gov/mdhhs" www.michigan.gov/mdhhs FAX: 517-335-0075  FORMCHECKBOX  Medicaid  FORMCHECKBOX  CSHCS1. Prior Authorization Number (MDHHS use only)Note: The provider is responsible for eligibility verification. Authorization does not guarantee beneficiary eligibility or payment. MDHHS requires that the MSA-1680-B be typewritten; handwritten forms will not be accepted.2. Provider Name (Last, First, Middle Initial)  FORMTEXT      7. Beneficiary Name (Last, First, Middle Initial)  FORMTEXT      3. Provider Street Address  FORMTEXT      8. Birth Date  FORMTEXT    /  FORMTEXT    /  FORMTEXT     9. Sex  FORMCHECKBOX  M  FORMCHECKBOX  F4. City  FORMTEXT      State  FORMTEXT   ZIP Code  FORMTEXT      10. MI Health Card Number  FORMTEXT      11. Phone Number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     5. Provider Fax Number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     6. Provider Phone Number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     12. Provider NPI Number  FORMTEXT      13. Group NPI Number  FORMTEXT      14. CSHCS Diagnosis  ICD Diagnosis Code and Description  FORMTEXT    . FORMTEXT     FORMTEXT       18. Indicate missing teeth with an  X - teeth to be extracted with a " / ". For Orthodontics: also Indicate erupted teeth with a circle 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 A B C D E F G H I J T S R Q P O N M L K 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 1715. Are radiographs attached?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If Yes, number of radiographs and date taken  FORMTEXT      FORMTEXT    /  FORMTEXT    /  FORMTEXT      Radiographs will only be returned upon request. Check here for return of radiographs  FORMCHECKBOX 16. Is treatment for orthodontics?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIs treatment plan enclosed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No19. Indicate crowns, dental implants, impacted teeth, bridges, and teeth extracted since radiographs:  FORMTEXT      17. Is this initial placement of prosthesis?  FORMCHECKBOX  Max.  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Mand.  FORMCHECKBOX  Yes  FORMCHECKBOX  No If No, please document reason for replacement:  FORMTEXT      20. Status of Current Prosthesis:EXAMINATION AND TREATMENT REQUESTEDCan BeUsed Now? Yes NoL I N E21. Tooth 22. Procedure Code23. Consultant Use Only24. Description of ServicePartFullDate InsertedWorn? Yes NoRepaired? 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Address 5 Year Prognosis for Partial Dentures  FORMTEXT      3 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      4 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      5 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      6 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      7 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      8 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      9 FORMTEXT    FORMTEXT       FORMTEXT       FORMTEXT      26. Other Pertinent Dental or Medical History  FORMTEXT       27. PROVIDER CERTIFICATION: The patient named above (parent, if minor, or authori`bdln،ڌ܌ތ &(*,02FӯӝӋysg_hkCJaJjhkCJUaJ hkCJ#j9h":mhkCJUaJ#j9h":mhkCJUaJ#j8h":mhkCJUaJ#j28h":mhkCJUaJ#j7h":mhkCJUaJhnhkCJaJjhnhkCJUaJ#jF7h":mhkCJUaJFHJLNPRThjlnprtvxz|čƍȍʍ̍΍Ѝ2Ʌy h-CJ hCJ h1CJ#j;hVxhkCJUaJ#j;hxehkCJUaJ#j:hhkCJUaJhkCJaJ hkCJ"jhkCJUaJmHnHujhkCJUaJ#j :hxehkCJUaJ/246JLNPRTVXZ\`bvxz|~뼼붶}qiWqq#jAhhkCJUaJhkCJaJjhkCJUaJhk"jhqTCJUaJmHnHujAhqTCJUaJhqTCJaJjhqTCJUaJ hkCJ"jhkCJUaJmHnHu#j@h chkCJUaJh chkCJaJjh chkCJUaJ hCJŽĎƎȎʎ̎ΎЎҎԎ "$&:<>齽齽yuc#jDhhkCJUaJhk#jIDh~hkCJUaJh~hkCJaJjh~hkCJUaJ hkCJ#jBhVxhkCJUaJ"jhkCJUaJmHnHu#j"BhxehkCJUaJhkCJaJjhkCJUaJhHohkCJaJ&& $$Ifa$gdkkd(C$$IfTl4 ֈ%*`:04 lapytT$Lt $$Ifa$gdk $Ifgdk>@BDFHJLNbdfhjlnprtvďƏȏ܏Ͻϫץyuhk#jzGh~hkCJUaJh~hkCJaJjh~hkCJUaJ hkCJ#jEhVxhkCJUaJ#jMEhxehkCJUaJhkCJaJhHohkCJaJjhkCJUaJ"jhkCJUaJmHnHu*& $$Ifa$gdkkdSF$$IfTl4 ֈ%*:04 lapytTƏ> $$Ifa$gdk $Ifgdk܏ޏ ,.02468:<>@BFH\^`ἼἘĒxf#jJh~hkCJUaJh~hkCJaJjh~hkCJUaJ hkCJ#jHhVxhkCJUaJ#j~HhxehkCJUaJhkCJaJhHohkCJaJ"jhkCJUaJmHnHujhkCJUaJ#jGhhkCJUaJ(>@B& B$IfgdkkdI$$IfTl4 ֈ%* :04 lapytTBFh $$Ifa$gdk $Ifgdk`bdfhj~ΐАҐԐ֐ؐڐܐސǵϪǘϪdžϪuh:YhkCJaJ hkCJ#j%LhVxhkCJUaJ#jKhxehkCJUaJhHohkCJaJ#j!KhhkCJUaJhkCJaJjhkCJUaJhkjh~hkCJUaJ"jhkCJUaJmHnHu)& $IfgdkkdL$$IfTl4 ֈ%* :04 lapytT "$&(*,.024HJLNPRTVXZ\prtvxz|~Ծ²{²i²#jPOhVxhkCJUaJ#jNhxehkCJUaJhHohkCJaJ#jLNhhkCJUaJhkCJaJjhkCJUaJhk"jhkCJUaJmHnHujh~hkCJUaJ#jMh~hkCJUaJh~hkCJaJ( 2Z $Ifgdk $$Ifa$gdk‘đƑȑʑ̑ΑБґԑ֑뼼븬uc#j{RhVxhkCJUaJ#jQhxehkCJUaJhHohkCJaJ#jwQhhkCJUaJhkCJaJjhkCJUaJhk"jhkCJUaJmHnHu#jPh~hkCJUaJh~hkCJaJjh~hkCJUaJ hkCJ&& C$IfgdkkdO$$IfTl4 ֈ%* :04 lapytTԑ$ $$Ifa$gdk $Ifgdk "$&(,.BDFHJLNPdfhjlnprtvxt#j*UhxehkCJUaJ#jThhkCJUaJhkCJaJhk#j&Th~hkCJUaJh~hkCJaJjh~hkCJUaJ hkCJhHohkCJaJ"jhkCJUaJmHnHujhkCJUaJ+$&(,& $IfgdkkdS$$IfTl4 ֈ%* :04 lapytT,Nvƒ $Ifgdk $$Ifa$gdk’ĒƒȒʒ̒&(<>@BDFHJLNPRTVXZ\^zľᰞᰖh[ h(ICJU h[,CJh[,CJaJ#jmWh chkCJUaJhkCJaJ hCJ hkCJhHohkCJaJ"jhkCJUaJmHnHujhkCJUaJ#jUhVxhkCJUaJ2ƒȒ&N& $Ifgdkkd0V$$IfTl4 ֈ%* :04 lapytTNPRTVXZ t!$Ifgd[ gkdW$$IfTlh**04 layt*YT $Ifgdk zed representative) understands the necessity to request prior approval for the services indicated above. I understand the services requested herein require prior approval and if submitted on the proper 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 material fact may be prosecuted under applicable Federal and State Law. Providers Name (printed/typed): Provider Signature: Date:     Page 1 of 2 MSA-1680-B (Rev. 4/21) Previous Editions Obsolete AUTHORITY: Title XIX of the Social Security Act The Department of Health and Human Services is an equal COMPLETION: Is Voluntary, but is required if payment from applicable program is sought. opportunity employer, services and programs provider. MSA-1680-B (Rev. 4/21) Previous Edition Obsolete. 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