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Page 1 of 2 MSA-1680-B Rev. 06/14 Previous Editions Obsolete For MDCH Consultant Use Only 1. Prior Authorization No. www. 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. MICHIGAN DEPARTMENT OF COMMUNITY HEALTH 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 Children s Special Health Care Services CSHCS. For authorization of orthodontics and/or crown and bridge services for beneficiaries enrolled in CSHCS please see the Children s Special Health Care Services Dental Services Section Dental Chapter of the Medicaid Provider Manual. The completed MSA-1680-B may be mailed or faxed depending whether x-ray films are necessary to Michigan Department of Community Health Dental Prior Authorization P. Approved services are required to be completed within a 180-day period. To request an extension the provider must submit a copy of the current MSA-1680-B 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 please see the Prior Authorization Section Dental Chapter of the Medicaid Provider Manual. Dental providers treating CSHCS beneficiaries are required to submit the beneficiary s CSHCS qualifying diagnosis. For beneficiaries enrolled in Healthy Kids Dental dentists should contact Delta Dental Plan for authorization requirements. This form is self-explanatory. If services are approved the provider will receive a copy of the form marked Approved and with a Prior Authorization number. O. Box 30154 Lansing MI 48909 Fax 517 335-0075 Questions should be directed to Dental Prior Authorization at 1-800-622-0276. michigan*gov/mdch Medicaid Note CSHCS Approval refers to service only and does not authorize fees or patient eligibility including age. 2. Provider Name Last First Middle Initial 9. Beneficiary Name Last First Middle Initial 3. Provider Street Address 4. Provider County 10. Birth Date / ZIP Code 11. Sex M 5. City State 12. MI Health Card Number 6. Provider Fax Number 7. Provider Phone Number 14. Does patient live in a nursing home F 13. Phone Number If Yes Facility Name - No Yes 8. Provider NPI No* 15. Is Patient Covered by Any Other Dental Plan 16. CSHCS Diagnosis ICD Diagnosis Code and Description If Yes Plan Name. 18. Are X-Rays Enclosed Number of X-Rays and Date Taken 19. Is Treatment for Orthodontics Is Treatment Plan Enclosed 22. Indicate missing teeth with an X - teeth to be extracted with a /. 9 10 11 12 13 14 A B C D E G H I S R Q P O N L K J T 20. Is this Initial Placement of Prosthesis Max. 32 31 30 Mand. 21. Status of Current Prosthesis Part Full EXAMINATION AND TREATMENT RECORD Can Be Date Inserted Worn Repaired Used Now Area of Oral Cavity Procedure Code Consultant Use Only Description of Service 29.

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