MODULE 1: AN OVERVIEW OF THE CURRENT PERSONAL CARE SERVICES (PCS) REQUEST FOR SERVICES FORM DMA 3051. HOW TO COMPLETE THE FORM FOR NEW REFERRALS, CHANGE OF STATUS AND CHANGE OF PROVIDER REQUESTS.
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MODULE 1: OVERVIEW OF CONSOLIDATED FORM DMA 3051
Personal Care Services (PCS) Request for Services forms have been consolidated into one form as of 10/1/13: PCS Request for Services DMA 3051
§ All PCS providers, regardless of se8ng, will use the DMA 3051 form.
§ DMA 3051 is the only form that will allow physicians to provide wriGen aGestaHon to the medical necessity for up to 50 addiHonal PCS hours.
§ Download the current form at:
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h"p://info.dhhs.state.nc.us/olm/forms/dma/dma-‐3051-‐ia.pdf
MODULE 1: OVERVIEW OF FORM DMA 3051
• DMA 3041 Home Care Agency • DMA 3068 Licensed ResidenHal Facility
Referral
• DMA 3042 Home Care Agency • DMA 3069 Licensed ResidenHal Facility
Change of Status
• DMA 3043 Home Care Agency • DMA 3070 Licensed ResidenHal Facility
Change of Provider
Form DMA 3051 replaced the following forms:
As of October 31, 2013 these forms are obsolete. 4/28/14 6
MODULE 1: OVERVIEW OF FORM DMA 3051 10/1/13
NEW REFERRAL
CHANGE OF
STATUS
CHANGE OF
PROVIDER
Form DMA 3051 Will Now Be Used For These Requests
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MODULE 1: COMPLETING PCS FORM DMA 3051
Key Information
§ The terms Beneficiary and Recipient will be used interchangeably throughout the modules.
§ The DMA 3051 form has 6 secHons – A through F. You are not required to complete all of the secHons of the DMA 3051 form each Hme you submit the form.
§ Complete only the secHons for the specific request being submiGed on behalf of the recipient.
§ Note: SelecHng the type of Provider and pu8ng a date on the request form are mandatory for all submiGals. Use mm/dd/yyyy forma8ng.
§ Refer to the Personal Care Services (PCS) Request for Services Form – DMA 3051 InstrucHons (effecHve 10/1/13) available at: hGp://info.dhhs.state.nc.us/olm/forms/dma/dma-‐3051-‐Hps.pdf
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MODULE 1: COMPLETING PCS FORM DMA 3051
NEW REFERRAL
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MODULE 1: COMPLETING PCS FORM DMA 3051
• Recipient Demographics SecHon A
• Recipient Medical History SecHon B
• New Referral Request SecHon C
For NEW Referral Requests, Complete The Following Sections
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MODULE 1: COMPLETING PCS FORM DMA 3051
New Referral: Section A Required Fields § Medicaid ID Number – Only acHve Medicaid parHcipants are eligible. § Enter Recipient Name, Date of Birth, Address and Phone. § Indicate the recipient’s alternate contacts: parent, guardian or legal representaHve.
§ PCS Provider name and phone should reflect the current provider informaHon when submi8ng.
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MODULE 1: COMPLETING PCS FORM DMA 3051
New Referral: Section B Required Fields
§ Enter the Medical Diagnosis and ICD-‐9 Code. § Enter “O” or “E” for Onset or ExacerbaHon. § Where known, enter the diagnosis date in mm/yyyy format. The date reflects either the date of onset, if it is a new diagnosis, or the date of the most recent exacerbaHon of a previous diagnosis. Note that the date of onset or exacerbaHon must be as close to the actual date as possible.
§ If the precise date is unknown, enter 00s in the month and note the year.
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MODULE 1: COMPLETING PCS FORM DMA 3051
New Referral: Section C Required Fields § Indicate if the recipient is medically stable. § Provide Referring EnHty’s name, NPI and phone number. § The last visit date must be completed and must have occurred within 90 days of the
Request For Services Form submission date. List the date in mm/dd/yyyy format. § The Request For Services Form for the New Referral MUST be signed by the referring
enHty: an MD/NP/PA. The signature date must be in mm/dd/yyyy format.
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MODULE 1: COMPLETING PCS FORM DMA 3051
New Referral: Sending The Completed Form
§ Complete SecHons A, B & C. § Please fax Page 1 of the completed form to:
919-‐307-‐8307 or 855-‐740-‐1600 (toll-‐free) § If you prefer, you may mail Page 1 of the form to:
Liberty Healthcare CorporaHon of NC AGn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606
§ If you have quesHons concerning the form, please email [email protected] or call 855-‐740-‐1400.
§ Keep copies of all forms and fax confirmaHons for your records.
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MODULE 1: COMPLETING PCS FORM DMA 3051
New Referral: What Happens Next
§ If the New Referral Request is complete and meets the requirements as outlined in Clinical Coverage Policy 3L, the Referral will be processed and entered into QiRePort.
§ If the informaHon is not complete, the New Referral Request form will be returned by Liberty Healthcare to the referring enHty via fax within 48 hours.
§ Liberty Healthcare will verify that the recipient has acHve Medicaid coverage. The recipient will be contacted by Liberty Healthcare to schedule a Medicaid PCS eligibility assessment.
§ If the recipient is determined to be eligible for PCS, the Provider of Choice will receive the referral via the QiRePort Provider Interface.
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MODULE 1: TECHNICAL DENIALS
Unable to Process Missing or Incorrect Information
Incomplete Missing Information
Complete
Non-Qualifying
A Personal Care Services
Request for Services may be denied.
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MODULE 1: TECHNICAL DENIALS
§ Recipient Name § Recipient Address § Medicaid Number § Date of Birth
§ Date of request § Referring EnHty’s name, signature and NPI (NaHonal Provider IdenHfier)
Unable to Process Due to Missing Information in
Required Fields
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MODULE 1: TECHNICAL DENIALS
§ No Date of Last Visit to the Referring EnHty.
§ Medical stability quesHon is not answered.
§ Medical Diagnosis is not indicated.
§ ICD-‐9 Code is missing.
Incomplete Due to Missing
Information in Required Fields
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MODULE 1: TECHNICAL DENIALS
§ The recipient is not a current Medicaid recipient.
§ The medical stability quesHon is marked “No.”
§ The date of the last visit to the referring enHty is more than 90 days from the submission date.
§ Adult recipient is currently receiving private duty nursing or CAP services.
Complete Non-Qualifying
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MODULE 1: COMPLETING PCS FORM DMA 3051
CHANGE OF
STATUS
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MODULE 1: COMPLETING PCS FORM DMA 3051
• Recipient Demographics SecHon A
• Recipient Medical History SecHon B
• Change of Status Request SecHon D
For Change of Status Requests, Complete The Following Sections
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MODULE 1: COMPLETING PCS FORM DMA 3051
Change of Status: Section D Required Fields
§ Select the box that most closely describes the reason for the change in condiHon.
§ Be sure to include specific changes in condiHon. § Indicate if the recipient is medically stable.
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WHEN SHOULD A CHANGE OF STATUS BE SUBMITTED?
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§ The recipient’s medical condiHon § Informal caregiver availability § Environmental condiHon or locaHon
When there has been a change in:
MODULE 1: COMPLETING PCS FORM DMA 3051
Change of Status: Sending The Completed Form
§ Complete SecHons A, B & D. § Please fax Page 1 & 2 of the completed form to:
919-‐307-‐8307 or 855-‐740-‐1600 (toll-‐free) § If you prefer, you may mail Page 1 & 2 of the form to:
Liberty Healthcare CorporaHon of NC AGn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606
§ If you have quesHons concerning the form, please email [email protected] or call 855-‐740-‐1400.
§ Keep copies of all forms and fax confirmaHons for your records.
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MODULE 1: COMPLETING PCS FORM DMA 3051
Change of Status: What Happens Next
§ Liberty Healthcare receives the Change of Status Request. § All informaHon will be checked for completeness. § If all informaHon is complete, the change of status request will be entered into qiRePort.
§ If the informaHon is not complete, the change of status request form will be returned to the referring enHty via fax within 48 hours.
§ Within 12 business days, Liberty Healthcare will contact the beneficiary to schedule an assessment.
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MODULE 1: COMPLETING PCS FORM DMA 3051
CHANGE OF
PROVIDER
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MODULE 1: COMPLETING PCS FORM DMA 3051
• Recipient Demographics SecHon A
• Change of Provider Request SecHon F
For Change of Provider Requests, Complete The Following Sections
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MODULE 1: COMPLETING PCS FORM DMA 3051
Change of Provider: Section F Key Points
§ A beneficiary may request Change of Provider by submi8ng this form or by calling Liberty Healthcare.
§ If a beneficiary needs assistance in selecHng an Alternate Preferred Provider, assistance can be provided by a Liberty Healthcare Customer Support RepresentaHve.
§ Liberty Healthcare will confirm all Change of Provider requests with the Beneficiary or legal guardian.
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MODULE 1: COMPLETING PCS FORM DMA 3051
Change of Provider: Section F Required Fields
§ Recipient’s Preferred Provider § Agency Name § Phone § NPI #
§ Contact InformaHon for QuesHons § Contact’s Name § Phone
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MODULE 1: COMPLETING PCS FORM DMA 3051
Change of Provider: Sending The Completed Form
§ Complete SecHons A & F. § Please fax Page 1, 2 & 3 of the completed form to:
919-‐307-‐8307 or 855-‐740-‐1600 (toll-‐free) § If you prefer, you may mail Page 1, 2 & 3 of the form to:
Liberty Healthcare CorporaHon of NC AGn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606
§ If you have quesHons concerning the form, please email [email protected] or call 855-‐740-‐1400.
§ Keep copies of all forms and fax confirmaHons for your records.
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MODULE 1: EXPEDITED ASSESSMENT PROCESS
Eligibility requirements:
§ There is an acHve Adult ProtecHve Services (APS) case § The beneficiary is currently hospitalized, in a medical facility or in a Skilled Nursing Facility (SNF).
§ For an Adult Care Home (excluding 5600 faciliHes), the beneficiary must have a Pre-‐Admission Screening and Resident Review (PASRR) number. To learn more this form and process, please go to www.ncmust.com/pasarr/pasarrsummary.jsp
§ The beneficiary is medically stable. § The beneficiary has acHve or pending Medicaid.
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MODULE 1: EXPEDITED ASSESSMENT PROCESS
§ If eligibility requirements are met, a hospital discharge planner, skilled nursing facility discharge planner or Adult ProtecHve Services (APS) Worker may request an Expedited Assessment by faxing the Request for Services form to 919-‐322-‐5942 followed by a call to Liberty Healthcare at 1-‐855-‐740-‐1400.
§ A hospital discharge planner, skilled nursing facility discharge planner or APS worker will need to have the beneficiary select a provider of services before PAs can be issued.
§ Expedited Assessments for beneficiaries seeking placement in ACHs (not 5600s) will need a PASRR number.
§ Once connected with Liberty, the request will be reviewed and immediately approved or denied by a Customer Service Team Member. If approved, the caller will be transferred to a Liberty Healthcare nurse who will conduct a brief telephone assessment. If approved, the beneficiary will be immediately awarded temporary hours for PCS services.
§ Liberty Healthcare will then contact the beneficiary within 14 business days to schedule a complete assessment in person.
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