Home Care Services Step 1 of 4 25% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Date of Birth* MM slash DD slash YYYY Member's Name* First Last Member's LOB Error Message Agency InformationHome Care Agency NPI* Home Care Agency Name* Error Message Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationOrdering Provider* Ordering Provider Phone #*Ordering Provider Fax #*Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Please Choose One:*Please Choose One: *Initial RequestContinuation of ServicesCorrectionPrevious Authorization or E-form Reference #* Please Choose Service*select all that apply Section A - Skilled Intermittent Home Health (Nursing, PT, OT, Speech Therapy, MSW, CNA) Section B - Non-Skilled Home Care (Nursing Evaluations/Assessments (T1001), CNA, Homemaker, and/or Combination Services) Section C - Private Duty Nursing (including Nursing Evaluations/Assessments (T1001) for PDN services) Section ASkilled Intermittent Home Health (Nursing, PT, OT, Speech Therapy, MSW, CNA) REQUIRED INFORMATION: New Start of Care & Evaluations: Referral from physician/facility, or discharge summary from facility *Only applies to one (1) visit for nursing, physical therapy, and/or occupational therapy Continuation of Care after Evaluation: Current completed OASIS with documentation of verbal orders received for all requested visits; and/or Current CMS-485 Home Health Certification and Plan of Care (CMS-485) signed by agency clinician that received verbal orders for the plan of care and/or signed by the practitioner; and Supporting documentation of the member’s need for skilled home health services, such as evaluations/assessments and progress notes for each requested discipline Recertification of Existing Services: CMS-485 signed by agency clinical that received verbal orders for the plan of care and/or signed by the practitioner; and Recertification assessment/evaluation for each requested discipline that addresses progress towards meeting goals with objective measurements, response/barriers to education/managing care, and adherence issues. Start Date*Please Note: Dates cannot overlap certification periods MM slash DD slash YYYY End Date* MM slash DD slash YYYY Date of Face-to-Face Encounter MM slash DD slash YYYY Date of D/C from facility (if applicable) MM slash DD slash YYYY Requested Service(s) with Provider Orders* Skilled Nursing (RN/LPN) HHA/CNA (part of skilled plan of care) Physical Therapy (PT) G0151 Occupational Therapy (OT) G0152 Speech Therapy (ST) G0153 Medical Social Worker (MSW) S9127 Skilled Nursing (RN/LPN): Choose the needed code(s)* T1030 T1031 S9097 Skilled Nursing (RN/LPN): Are you requesting initial evaluation visit only?*Skilled Nursing (RN/LPN): Are you requesting initial evaluation visit only? *YesNoSkilled Nursing (RN/LPN): Start of Care Date* MM slash DD slash YYYY Skilled Nursing (RN/LPN): Quantity of Visits (not units)*Requested Number of Visits from Plan of CareNumber of Requested Visits that were already completed HHA/CNA: Choose the needed code*HHA/CNA: Choose the needed code *G0156 (Medicaid & INTEGRITY)S5125 (Commercial)HHA/CNA (Part of a Skilled Plan of Care): Quantity of Visits (not units)*Requested Number of Visits from Plan of CareNumber of Requested Visits that were already completed Physical Therapy (PT): Are you requesting initial evaluation visit only?*Physical Therapy (PT): Are you requesting initial evaluation visit only? *YesNoPhysical Therapy (PT): Start of Care Date* MM slash DD slash YYYY Physical Therapy (PT): Quantity of Visits (not units)*Requested Number of Visits from Plan of CareNumber of Requested Visits that were already completed Occupational Therapy (OT): Are you requesting initial evaluation visit only?*Occupational Therapy (OT): Are you requesting initial evaluation visit only? *YesNoOccupational Therapy (OT): Start of Care Date* MM slash DD slash YYYY Occupational Therapy (OT): Quantity of Visits (not units)*Requested Number of Visits from Plan of CareNumber of Requested Visits that were already completed Speech Therapy (ST): Are you requesting initial evaluation visit only?*Speech Therapy (ST): Are you requesting initial evaluation visit only? *YesNoSpeech Therapy (ST): Start of Care Date* MM slash DD slash YYYY Speech Therapy (ST): Quantity of Visits (not units)*Requested Number of Visits from Plan of CareNumber of Requested Visits that were already completed Medical Social Worker (MSW): Quantity of Visits (not units)*Requested Number of Visits from Plan of CareNumber of Requested Visits that were already completed Section BNon-Skilled Home Care (Regulatory Nursing Evaluations/Assessments (T1001), CNA, Homemaker, and/or Combination Services) REQUIRED INFORMATION: INTEGRITY (MMP): Clinical documentation is not required but the requested hours and services must match the hours and services the member’s care manager approved as medically necessary. Medicaid (RHE, RHP, MED, CSN, SUB): New Start of Care or Increased Services: Documentation that the services are part of a physician’s plan of care, such as doctor’s orders, letter of medical necessity, referral, etc., AND Provide documentation indicating the level of assistance the member needs with each Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs), such as a completed Minimum Data Set (MDS) for Home Care signed by a nurse within the last 90 days or a completed Provider Medical Statement (PM1) from the member’s physician within the last year, AND Current aide plan of care Continuation of Services: See the second bullet point in the New Start of Care or Increased Services section above; AND Current aide plan of care Nurse Assessment (T1001) – No authorization is required for the first 6 visits per member, per agency in a rolling year. Explanation of the need for the visits being requested and for the 6 visits already completed. Please Choose service* Combination Services (S5125 U1): Personal care and homemaking services performed by an HHA/CNA during the same session High Acuity Combination Services (S5125 U1 U9): Please note: you must submit a completed Home Care MDS form if choosing this option Homemaker Services Only (S5130) CNA Services Only (S5125) Combination Services (S5125 U1) : Number of hours / week*Please enter a number from 0 to 168.High Acuity Combination Services (S5125 U1 U9) : Number of hours / week*Please enter a number from 0 to 168.Homemaker Services Only (S5130) : Number of hours / week*Please enter a number from 0 to 168.CNA Services Only (S5125) : Number of hours / week*Please enter a number from 0 to 168.Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed?*Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed? *YesNoNumber of Nursing Visits Needed* Start Date* MM slash DD slash YYYY End Date (not to exceed 26 weeks)* MM slash DD slash YYYY Indicate if the HHA hours are requested for:* Work School or Daycare Before/After School or Daycare None Assessment of Member's Activities of Daily Living*Assessment of Member's Activities of Daily Living *N/A - Member is an INTEGRITY memberCompleted Home Care MDS or PM1 is attachedSection CPrivate Duty Nursing (including Nursing Evaluations/Assessments (T1001) for PDN services) REQUIRED INFORMATION: **If transferring hours between agencies, then a Release of Hours Letter is needed from the agency releasing the hours that includes: the number of hours released to the new agency, the start date of the transfer, and the end date of the transfer (if applicable) New Start of Care and Continuation of Care: Current, comprehensive Plan of Care (POC) signed by agency clinician that received verbal orders for the plan of care and/or signed by the Physician. All PDN requests require ongoing supervision by the treating physician. Up to two (2) weeks of the most recent nursing notes detailing all nursing interventions and care provided during the nurses’ shift. If applicable, provide a complete description of any wounds: size, depth, drainage, type, and wound care orders. If a member has a change in condition or caregiver status that requires additional PDN coverage, you can submit a request to increase hours at any time with supporting documentation to be reviewed. Nurse Assessment (T1001) – No authorization is required for the first 6 visits per member, per agency in a rolling year. Explanation of the need for the visits being requested and for the 6 visits already completed. Indicate if the PDN hours are requested for:* Work School or Daycare Before/After School or Daycare None Number of hours / week (not units)*Please enter a number from 0 to 168.PDN: Choose the needed code(s)* T1002 T1003 Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed?*Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed? *YesNoNumber of Nursing Visits Needed* Start Date* MM slash DD slash YYYY End Date (not to exceed 13 weeks)* MM slash DD slash YYYY Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Physician or Licensed Provider (Required for skilled service)*Signature Date:* Consent* Per EOHHS, Neighborhood cannot pay for services provided by individuals that reside with the member, have a family relationship to the member as defined by RI General Laws, 210-RICR-20-05-1, or are legally responsible for the member. I attest that contracted services provided to this member will not be rendered by such specified persons.Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHAConsent I agree to the privacy policy.