Michigan Medicaid requires prior authorization through the Program Review Division for certain medical equipment and services, and MSA-1653-B is the request suppliers fax for them. DME and medical suppliers, orthotists, prosthetists, hearing aid dealers, audiologists and cochlear manufacturers use it for fee-for-service Medicaid and CSHCS beneficiaries. The ordering practitioner is named on the form, and their records support the request.
The requesting Medicaid-enrolled supplier completes boxes 1 to 29 and signs the provider certification. The referring or ordering physician, physician assistant or advanced practice registered nurse is identified by name, NPI and address in boxes 6 to 8, and their order and clinical documentation go with the request.
Download the current version from the source each time; forms change without notice.
Special Services Prior Authorization Request
Michigan Department of Health and Human Services, Program Review Division takes this form through its online services or your EMR, so there is no PDF to fill. Vero Scribe writes the visit note it draws on, so the details are ready when you complete it.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. The form states it is not required when the request is submitted by direct data entry in the CHAMPS Provider Portal. Supporting clinical documents are uploaded to the request there, each showing the beneficiary's name and mihealth card number. The form is required only for faxed submissions to the Program Review Division.
No. The supplier, or its representative, prints their name, signs and dates the provider certification, and requests without it are returned. The referring or ordering physician, physician assistant or advanced practice registered nurse is listed with name, NPI and address, and their order and medical records support the medical need.
The instructions say standard reviews are determined within 7 calendar days. Expedited review applies when the item must be provided within 10 calendar days for medical necessity; if a request does not meet the expedited criteria, it is processed as standard and the supplier is notified in CHAMPS.