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 ServicesPrevious Authorization # 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) NOTE: Only CMS Certified Agencies can provide this service per RI General Laws, 210-RICR-20-05-1 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) Occupational Therapy (OT) Speech Therapy (ST) Medical Social Worker (MSW) 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): Date nursing services started* 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 (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): Date PT services started* 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): Date OT services started* 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): Date ST services started* 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 for Duals (FIDE): 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, Increased Services, and Continuation of 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. (NOTE: Doctor's orders have to be renewed annually), 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 Nurse Assessment (T1001) – No authorization is required for the first 6 visits per member, per agency in a calendar year. Explanation of the need for the visits being requested and the dates and reasons 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? *YesNo*Only request if more than 6 visits are needed in a calendar year.Has the member already had 6 nursing visits with your agency in the last calendar year?*Has the member already had 6 nursing visits with your agency in the last calendar year? *YesNoYou will not be able to proceed with requesting T1001 because your agency has not already provided 6 of these visits in the calendar year. Therefore, no authorization is required at this time. You must update your answer to "No" for the "Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed?" question above. Dates and reasons for previous 6 visits this calendar year:*Number of Nursing Visits Needed* Start Date* MM slash DD slash YYYY End Date (not to exceed 26 weeks)* MM slash DD slash YYYY Assessment of Member's Activities of Daily Living*Assessment of Member's Activities of Daily Living *N/A - Member is an INTEGRITY for Duals memberCompleted and Signed 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 calendar year. Explanation of the need for the visits being requested and the dates and reasons for the 6 visits already completed Number of hours / week (not units)*Please enter a number from 0 to 168.Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed?*Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed? *YesNo*Only request if more than 6 visits are needed in a calendar year.Has the member already had 6 nursing visits with your agency in the last calendar year?*Has the member already had 6 nursing visits with your agency in the last calendar year? *YesNoYou will not be able to proceed with requesting T1001 because your agency has not already provided 6 of these visits in the calendar year. Therefore, no authorization is required at this time. You must update your answer to "No" for the "Regulatory Nursing Evaluation/Assessment Visits (T1001) Needed?" question above. Dates and reasons for previous 6 visits this calendar year:*Number 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 *Standard - defaultedExpedited: By checking Expedited, you are stating that processing this request in the standard time (7 days for Medicaid and D-SNP; 15 days for Commercial) 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.