Michigan Medicaid's Program Review Division uses MSA-6544-B for prior authorization of practitioner services, including out-of-state care, for fee-for-service Medicaid and Children's Special Health Care Services (CSHCS) beneficiaries. Practitioners need it only when faxing a request: entering the request in the CHAMPS Provider Portal with the Supplemental Information section completed makes the form unnecessary. Standard reviews are decided within 7 calendar days.
The requesting provider's office completes boxes 1 to 29, including the referring or ordering practitioner (physician, PA or APRN), beneficiary details from the mihealth card, HCPCS codes, quantities, diagnoses and the documentation checklist. The provider or representative prints, signs and dates the certification.
Download the current version from the source each time; forms change without notice.
Practitioner 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 is not required when the request is entered in CHAMPS through direct data entry and the Supplemental Information section is fully completed, with supporting documents uploaded to the request. It is required only for faxed submissions to the Program Review Division.
The instructions say standard reviews are determined within 7 calendar days. Expedited review applies when the service must be provided within 10 calendar days for medical necessity; if a request does not meet expedited criteria, it is processed as standard and the provider is notified in CHAMPS.
No. It is for fee-for-service Medicaid and Children's Special Health Care Services. For beneficiaries in Medicaid Health Plans, other managed care plans or Healthy Kids Dental, providers contact the assigned plan for its authorization requirements.