MedicaidPrior AuthHigh impact
MSA 16-15
Michigan Medicaid - MDHHS·MI·Provider Bulletin
Effective date
Jul 1, 2016
We identified it
Jun 20, 2026
Summary
Michigan Medicaid requires a new form (MSA-6544-B) for all prior authorization requests for special services including surgeries, procedures, office-administered drugs, and out-of-state care. All requests must now include this completed form plus supporting medical documentation.
Action Required
By July 1, 2016: All providers must use the new MSA-6544-B form for prior authorization requests for surgeries, clinical procedures, office-administered pharmaceuticals/biologicals, and out-of-state care. Download the form from www.michigan.gov/medicaidproviders and update PA request workflows to include completed form plus supporting documentation. Submit via DDE through CHAMPS or mail/fax to MDHHS Program Review Division.