Form Map 650 - Epsdt Special Services Home Health Fax Form - Kentucky Cabinet For Health And Family Services Department For Medicaid Services Page 3
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4Commonwealth of Kentucky
Map -650
Cabinet for Health and Family Services
(Rev 11/08)
Department for Medicaid Services
EPSDT Special Services Home Health Fax Form
Explanation and Instructions
The EPSDT Special Services Fax Form is used by EPSDT Special Services providers for private duty nursing
services, physical therapy, occupational therapy and speech therapy preauthorizations.
The form is designed to be a complete and thorough instrument that is:
1. Utilized for the home health agency to certify that the recipient medically needs the service;
2. Utilized to document that the care coordinator and therapists have reviewed the plan of care and updated as
needed;
3. Utilized to document that the service location is part of the preauthorization process;
4. Utilized by SHPS as an accessory tool to approve or deny EPSDT Special Services.
General Information
All EPSDT Special Services must be prior authorized.
It is the provider’s responsibility to verify patient eligibility every month before providing the services.
When services are requested, it is important to “paint a picture” for the reviewer, so that all-relevant information about
the case is presented. KCHIP Phase III children are not eligible for EPSDT Special Services-
Preauthorization is done on a case by case basis based on the medical necessity for the service.
If a preauthorization is requested, a letter with the PA number will be issued in 5-7 working days. If you have not
received the letter in 5-7 working days, call SHPS back and follow-up.
Always look at your PA letter before billing the claim. Make sure the number of units, dates, codes and money
amounts are correct before billing.
The time frames for authorization for services depend on the actual service:
Therapy – six months
Private Duty Nursing – two months
Important phone numbers:
SHPS – 800-292-2392
EDS Provider Enrollment – 877-838-5085
EDS Provider Relations – 800-807-1232
Medicaid EPSDT Special Services – 502-564-6890
Filling Out the Fax Form
1.
Date- Enter the date fax form filled out by provider
2.
Reviewing Nurse- Enter name of the SHPS Reviewing Nurse that your agency contact person spoke with
about the preauthorization
3.
Fax #- Enter the fax number to which your agency would like the response returned
4.
Reference #- Enter SHPS’s internal tracking number they assign (this is not the same number as the
preauthorization number), if known
5.
New Certification- Enter if a new service certification – write “yes,” if not, leave blank
6.
Recert- Enter if a recert write “yes,” if not, leave blank
7.
Change- Enter if a change occurs in the current treatment or goals and is documented with a doctor’s order
8.
EPSDT Provider Name- Enter your agency name
9.
Provider #- Enter the EPSDT Special Services provider number
10.
Contact name- Enter the name of the person from the agency who called in the review
11.
Agency address- Enter the street address, city and state
12.
Phone #- Enter the provider phone number
13.
Patient Name- Enter the first, middle and last name of recipient
14.
Address- Enter the patient address
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