Nf Peti Medical Necessity Certification Form

ADVERTISEMENT

NF PETI Medical Necessity Certification Form
Health Insurance Premiums, Deductibles or Coinsurance Criteria
Client name_________________________________________
Medicaid State ID Number _____________
1.
Medicare premiums are not an allowable deduction except in “Medicaid only” eligibility
cases and only for the first two months of Medicaid eligibility. The nursing facility shall
check with the county technician.
2.
Health insurance premiums, deductibles, and coinsurance shall be reviewed by the
Department or their designee for final approval.
If duplicate coverage has been
purchased, only the cost of the least expensive policy shall be allowed. Premiums,
deductibles, and coinsurance amounts that are not cost effective in relation to Medicaid
shall be disallowed.
3.
Health insurance premiums shall be allowed for the nursing facility resident only.
4.
Retroactive requests for NF PETI health insurance shall contain documentation of
medical services paid by the policy during the time period for which retroactive coverage
is requested.
5.
There is no NF PETI coverage for health insurance premiums, deductibles or
coinsurances that are incurred before the client’s first date of Medicaid eligibility.
6.
Do not submit health insurance requests until a Medicaid State identification number has
been assigned.
Facility Instructions
1.
The primary care physician shall make a statement of necessity for medical health
insurance.
2.
Health insurance premiums shall be approved by the Department. They shall be billed
monthly for on-going health insurance and shall not be included in the first $400
approved by the facility.
3.
Enter the monthly health insurance premium amount: $____________
4.
List the dates of coverage requested: __________________________
5.
Provide documentation of coverage by attaching a copy of the cover sheet of the health
insurance policy/policies and a copy of the client’s health insurance identification card.
6.
Attach a copy of the itemized statement verifying the monthly cost of the premium.
7.
Attach a copy of the client’s benefits summary for claims paid by the policy during the
period for which the backdate is requested.
8.
Has this client been hospitalized in the last year? __ Was this covered by the policy? __
9.
NF PETI coverage of health insurance premiums is limited to a maximum of 12 months
per NF PETI request. A new NF PETI must be submitted annually for approval.
Requested NF PETI health insurance monthly amount:_________
I agree with this request.
Signature of attending physician ____________________________ Date______ License #_____
Signature of Client/Responsible Party ______________________________Relationship_______
Revised August 2005

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go