Dma Certification Of Need For Medicaid Inpatient Psychiatric Services In A Psychiatric Residential Treatment Facility (Prtf) For A Recipient Under The Age Of 21 printable pdf download

Dma Certification Of Need For Medicaid Inpatient Psychiatric Services In A Psychiatric Residential Treatment Facility (Prtf) For A Recipient Under The Age Of 21

North Carolina

Department of Health and Human Services

Division of Medical Assistance

Clinical Policy and Programs

2501 Mail Service Center - Raleigh, N.C. 27699-2501

DMA Certification Of Need For Medicaid Inpatient Psychiatric Services

In A Psychiatric Residential Treatment Facility (PRTF)

For A Recipient Under The Age Of 21

Recipient Name: _____________________

Facility Name: ___________________________

Medicaid ID #: _______________________

Provider #: ______________________________

Date of Birth: _______________________

Admission Date: _________________________

Type of Certification: (check 1 item)

Medicaid Eligibility Status: (check 1 item)

⁯Pre-admission/elective

⁯Medicaid eligible on admission

⁯Pending Medicaid on admission

⁯No evidence of Medicaid on admission

⁯Applied for Medicaid during stay

⁯Applied for Medicaid after discharge

At the time of admission, the interdisciplinary team certifies the following:

1. Ambulatory care resources in the community do not meet the treatment needs of the recipient.

2. Proper treatment of the recipient’s condition requires services on an inpatient basis under the direction of a physician.

3. The inpatient services can reasonably be expected to improve the recipient’s condition or prevent further regression so

that services will no longer be needed.

________________________________

___________________________

_______________

Physician Team Member

Print Name/Title

Date (Mo/Day/Yr)

______________________________

_________________________

______________

Other Team Member Signature

Print Name/Title

Date (Mo/Day/Yr)

Please submit to the appropriate UR Vendor when completed.

The Durham Center (Durham County)

Eastpointe LME (Duplin, Lenoir, Sampson, and Wayne Counties)

ValueOptions

REVISED 08/16/01

Dma Certification Of Need For Medicaid Inpatient Psychiatric Services In A Psychiatric Residential Treatment Facility (Prtf) For A Recipient Under The Age Of 21

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