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Preview - Ohio Odm 02374 Form

Ohio Department of0HGLFDLG

PRIVATE DUTY NURSING (PDN) SERVICES REQUEST

INITIAL

RECERTIFICATION

CHANGE

Medicaid will automatically deny Prior Authorization (PA) Requests for clients who are not Medicaid eligible on the date of service. To avoid this, providers must determine consumer eligibility before requesting prior authorization.

CONSUMER INFORMATION (Complete entirely for all requests.)

Consumer Name (First, MI, Last)

Date of Request

Street Address

 

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

Phone Number (Area Code and Number)

 

 

County of Residence

 

 

 

 

 

 

 

 

 

Medicaid Number (12 digits)

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

 

 

 

Name of Parent or Guardian

 

 

 

Phone Number(s)

 

 

 

 

 

 

 

 

 

Waiver Type (Check)

 

 

 

 

 

 

 

ODA-Administered Waiver

DODD-Administered Waiver

No Waiver

 

I am requesting to receive private duty nursing services. I have authorized this case manager or provider to submit this request as written. I authorized 0HGLFDLG, the case manager, and the provider listed below, or the ODA-Administered or DODD-Administered Waiver case manager to exchange protected health information related to the assessment for and provision of private duty nursing services contained within this request.

 

Consumer’s or Authorized Representative’s Signature

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER INFORMATION (Complete entirely for all requests.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Name (First, MI, Last)/Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Phone Number

Fax Number

 

Email Address

 

 

 

 

 

 

 

 

 

 

Ohio Medicaid Provider Number 7 digits (Required)

National Provider Identifier Number

Nursing License Number

 

 

 

 

 

 

 

 

 

 

 

The individual submitting this form certifies that the information provided is true, accurate, and complete. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal or State funds may be prosecuted under Federal or State laws.

ODA OR DODD CASE MANAGER INFORMATION

(Request MUST be submitted to 0HGLFDLGby the CASE MANAGER if receiving ODA-Administered or DODD –Administered waiver services.)

 

Case Manager Name

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

Fax Number

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

Medicaid APPROVAL (For State use only)

 

 

 

 

 

PDN Services Approved

 

Number of Base and Sub Units Per Day, and Number of Hours Authorized Per Week

 

YES

NO

 

 

 

 

 

 

Scope of Services Approved

 

 

 

 

 

 

 

 

 

 

 

 

Duration of Services Approved

 

 

 

 

 

 

From

To

 

 

 

 

 

 

 

 

 

ODJFS Approved By

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

Additional Comments

 

 

 

 

 

 

NOTE: Prior approval by 0HGLFDLG only authorizes service delivery. It does not guarantee a consumer’s Medicaid eligibility It is the provider’s responsibility to check a consumer’s Medicaid eligibility each month.

2'0

)RUPHUO\JFS 02374 (Rev. 8/2012)3age 1 of 2

REQUEST FOR PDN SERVICES BEYOND THE 60-DAY POST-HOSPITAL STATE PLAN BENEFIT

The consumer’s attending physician identifies the need for PDN beyond what the State Plan 60 day Private Duty Nursing Post Hospital Benefit provides. An agency or independent provider must be found and agree to take care of the consumer. The request for PDN services must come from the provider or case manager if consumer is enrolled on an ODA-Administered or DODD-Administered waiver. A signed letter must be obtained from the physician that substantiates the need for the increased PDN hours and sent with the PDN request form. The letter must contain at minimum the following:

•The current diagnosis and the history of the illness

•The projected date of hospital discharge

•The estimated amount, frequency and duration of the services

•The expected skilled, continuous nursing interventions with the frequency of those interventions specified.

A temporary prior authorization number may be issued for a limited time until a face to face assessment can be completed.

NOTIFICATION OF PROVISION OF EMERGENCY SERVICES (Complete for recertification requests only.)

Pursuant to OAC 5101:3-12-02.3(E)(1) PDN services may be delivered in an emergency and a new PDN authorization obtained after the delivery of services. The PDN services must be medically necessary in accordance with OAC 5101:3-1-01 and the services must be necessary to protect the health and welfare of the consumer. (Emergency services are provided outside normal State of Ohio office hours when prior approval cannot be obtained.) Notification must be submitted no later than the first business day following service provision.

List Emergency Services Provided

Reason for Emergency

Number of Units of Service Provided Per Day

Number of Days of Service Provided Per Week

Consumer Name

Medicaid Number

REQUEST FOR CHANGE IN SERVICES (INCREASE, DECREASE, TERMINATION, WITHDRAWAL)*

(Complete for recertification requests only.)

Amount of Services Currently Being Received

Duration of Services Currently Being Received (List dates)

 

From

To

Amount of Services Being Requested

Duration of Services Being Requested (List dates)

 

From

To

Reason for Request (If increase, please include justification for increase with supporting documentation (Physician orders, visit notes, increased skilled nursing interventions, 485, etc)

*The individual submitting this form certifies that the information provided is true, accurate, and complete. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal or State funds may be prosecuted under Federal or State laws.

Independent and Agency Providers

This form must be submitted via the Medicaid MITS Web Portal:

http://medicaid.ohio.gov/providers/mits.aspx

No faxes or emails will be accepted for PDN requests.

For DODD Service Coordinators and PASSPORT Case Managers ONLY

Email or fax the completed form to:

Ohio Department of 0HGLFDLG Bureau of Long Term Care Services and Supports

EMAIL: pdn_bcsp@PHGLFDLG.ohio.gov FAX: 614-387-7661

If questions call: 614-466-6742

ODM 02374 (7/2014)

 

Formerly JFS 02374 (Rev. 8/2012)

Page 2 of 2

Document Properties

Fact Name Description
Form Purpose The Ohio ODM 02374 form is used to request initial recertification or changes for Private Duty Nursing (PDN) services under Medicaid.
Eligibility Requirement Providers must verify consumer eligibility for Medicaid before submitting a prior authorization request to avoid automatic denial.
Governing Laws The form is governed by Ohio Administrative Code (OAC) 5101:3-12-02.3 and OAC 5101:3-1-01.
Emergency Services Provision PDN services may be provided in emergencies, and a new authorization must be obtained afterward, with notification required by the next business day.
Submission Guidelines All requests must be submitted via the Medicaid MITS Web Portal; no faxes or emails will be accepted for PDN requests.

Documents used along the form

The Ohio ODM 02374 form is utilized for requesting private duty nursing services. Several other forms and documents are commonly associated with this process to ensure proper authorization and documentation. Below is a list of these related forms, each described briefly for clarity.

  • Ohio Medicaid Application: This form is necessary for individuals seeking Medicaid eligibility. It collects personal, financial, and medical information to determine if the applicant meets the criteria for Medicaid services.
  • Prior Authorization Request Form: This document is used to request approval from Medicaid for specific services before they are provided. It includes details about the service, the provider, and justification for the need.
  • Physician's Order: A signed document from a physician that outlines the medical necessity for private duty nursing services. This order must specify the type and frequency of services required for the consumer.
  • Emergency Services Notification: This form is completed when emergency nursing services are provided without prior authorization. It documents the nature of the emergency and the services delivered, ensuring compliance with Medicaid regulations.
  • Change of Services Request Form: This form is used when there is a need to modify the current level of services. It requires details about the existing services and justification for the requested changes.
  • California Power of Attorney Form: This legal document allows an individual to designate another person to make decisions on their behalf regarding financial and healthcare matters, ensuring that their wishes are honored during critical times. More information can be found at documentonline.org/blank-california-power-of-attorney.
  • Consumer Assessment Tool: This tool is utilized to evaluate the needs of the consumer and determine the appropriate level of care. It assesses various factors, including health status and support requirements.
  • Waiver Services Agreement: This agreement outlines the terms and conditions of the services provided under Medicaid waivers. It includes consumer rights and responsibilities, as well as provider obligations.
  • Service Delivery Log: A record maintained by the provider detailing the services rendered to the consumer. This log includes dates, times, and types of services provided, which is essential for billing and compliance purposes.
  • Case Manager Documentation: This includes notes and reports from the case manager regarding the consumer’s progress, needs, and any changes in the care plan. It is crucial for ongoing assessment and service coordination.

These forms and documents play vital roles in the process of obtaining and managing private duty nursing services in Ohio. Proper completion and submission of these materials help ensure that consumers receive the necessary care while adhering to Medicaid guidelines.

Guidelines on Filling in Ohio Odm 02374

Filling out the Ohio ODM 02374 form requires careful attention to detail. Each section must be completed accurately to ensure the request for private duty nursing services is processed smoothly. Follow these steps to fill out the form correctly.

  1. Begin with the Consumer Information section. Enter the consumer's full name, date of request, street address, city, state, zip code, phone number, county of residence, Medicaid number, date of birth, and the name and phone number of the parent or guardian.
  2. Indicate the waiver type by checking the appropriate box: ODA-Administered Waiver, DODD-Administered Waiver, or No Waiver.
  3. Confirm the request for private duty nursing services and authorize the case manager or provider to submit the request. Include the consumer’s or authorized representative’s signature and the date.
  4. Move to the Provider Information section. Fill in the provider's name, street address, city, state, zip code, phone number, fax number, email address, Ohio Medicaid provider number, and nursing license number.
  5. Certify the information provided in this section is true, accurate, and complete by signing where indicated.
  6. If applicable, complete the ODA or DODD Case Manager Information section with the case manager's name, phone number, fax number, and email address.
  7. Leave the Medicaid Approval section blank, as this is for state use only.
  8. If requesting services beyond the 60-day post-hospital benefit, include a signed letter from the attending physician detailing the need for increased PDN hours.
  9. For emergency services, provide the necessary details in the designated section, including the reason for the emergency and the number of units of service provided.
  10. If requesting a change in services, specify the current and requested amounts and durations, along with the reason for the request.
  11. Finally, submit the completed form via the Medicaid MITS Web Portal. Ensure no faxes or emails are sent for PDN requests.

After completing the form, ensure all information is accurate before submission. This will help avoid delays in processing your request for private duty nursing services.

Common mistakes

Filling out the Ohio ODM 02374 form can seem straightforward, but there are common mistakes that can lead to delays or denials in service requests. One frequent error is not verifying the consumer's Medicaid eligibility before submitting the form. It's crucial to check that the consumer is eligible on the date of service. If this step is overlooked, Medicaid will automatically deny the prior authorization request.

Another common mistake is incomplete consumer information. Each section of the form must be filled out entirely. Missing details, such as the consumer's Medicaid number or date of birth, can result in processing delays. Ensure that every field is completed to avoid unnecessary setbacks.

People often forget to include the required signatures. The consumer or their authorized representative must sign the form to confirm the information is accurate and to authorize the case manager or provider to submit the request. Without this signature, the form is considered invalid.

Additionally, many individuals neglect to provide a signed letter from the physician when requesting private duty nursing services beyond the standard 60-day post-hospital benefit. This letter is essential and should include specific details about the consumer’s condition and the necessity for increased services. Omitting this documentation can lead to a denial of the request.

Another frequent error involves the submission method. Some individuals mistakenly send the form via fax or email, which is not accepted for PDN requests. All submissions must go through the Medicaid MITS Web Portal. Following the correct submission process is vital to ensure timely processing.

Lastly, failing to provide adequate justification for changes in services can cause issues. If requesting an increase in services, it's important to include supporting documentation, such as physician orders or visit notes. Without this information, the request may not be approved. Being thorough and accurate in these details can make a significant difference in the outcome of the request.

FAQ

  1. What is the purpose of the Ohio ODM 02374 form?

    The Ohio ODM 02374 form is used to request Private Duty Nursing (PDN) services for individuals who are eligible for Medicaid. This form is essential for obtaining prior authorization for these services, ensuring that the necessary care can be provided to eligible consumers.

  2. Who needs to fill out the ODM 02374 form?

    Both the consumer and the provider must complete sections of the ODM 02374 form. The consumer's information, including their name, address, and Medicaid number, must be provided. Additionally, the provider's information, such as their name, agency details, and Medicaid provider number, must also be filled out accurately.

  3. What happens if a consumer is not Medicaid eligible on the date of service?

    If a consumer is not Medicaid eligible on the date of service, Medicaid will automatically deny the prior authorization request. Therefore, it is crucial for providers to verify the consumer's eligibility before submitting the form to avoid delays or denials in service provision.

  4. What information is required from the attending physician for increased PDN services?

    When requesting PDN services beyond the 60-day post-hospital benefit, a signed letter from the attending physician is necessary. This letter must detail the consumer's current diagnosis, history of the illness, projected discharge date, and the estimated frequency and duration of the required nursing services.

  5. How should emergency PDN services be reported?

    For emergency PDN services, notification must be submitted no later than the first business day following the provision of services. The form should include details about the emergency services provided, the reason for the emergency, and the number of service units delivered per day and week.

  6. What is the process for requesting a change in PDN services?

    To request a change in PDN services—whether an increase, decrease, termination, or withdrawal—one must complete the appropriate section of the ODM 02374 form. This includes detailing the current and requested services, their durations, and providing justification for any increases with supporting documentation.

  7. Where should the ODM 02374 form be submitted?

    The ODM 02374 form must be submitted via the Medicaid MITS Web Portal. Fax or email submissions are not accepted for PDN requests. However, for DODD Service Coordinators and PASSPORT Case Managers, the completed form can be emailed or faxed to the specified contacts at the Ohio Department of Medicaid.

  8. What are the consequences of providing false information on the ODM 02374 form?

    Submitting false, misleading, or incomplete information on the ODM 02374 form can lead to serious consequences. Misrepresentation may result in prosecution under federal or state laws, highlighting the importance of accuracy and honesty in all submissions.