Fillable Medical Eligibility Review Form (Page 2 of 4) in pdf

Applicant Name ____________________________

Part C – MR/MI Please Complete the Following on All Individuals:

Answer

Review Item

1. Is there a diagnosis or presenting evidence of mental retardation/related condition, or has the client received

MR services within the past two years?

2. Is there any presenting evidence of mental illness?

Please note: Dementia/Alzheimer’s is not considered a mental illness.

a. If yes, check all that apply.

Schizophrenia

Personality disorder

Somatoform disorder

Panic or severe anxiety disorder

Mood disorder

Paranoia

Other psychotic or mental disorder leading to chronic disability

3. Has the client received inpatient services for mental illness within the past two years?

4. Is the client on any medication for the treatment of a major mental illness or psychiatric diagnosis?

a. If yes, is the mental illness or psychiatric diagnosis controlled with medication?

5. Is the client a danger to self or others?

Part D – Diagnoses

Primary diagnosis related to the

need for requested level of care

ICD Code

Description

Other active diagnoses related to

the need for requested level of care

Descriptions

Part E – Skilled Services:

Requires a physician’s order. Requires the skills of technical or professional personnel such as a registered nurse,

licensed practical nurse, respiratory therapist, physical therapist, and/or occupational therapist. The service must be

inherently complex such that it can be safely and effectively performed only by, or under the supervision of, professional

or technical personnel. Items listed under Rehabilitation and Extensive Services may overlap.

Table I. Extensive Services (serious/unstable medical condition and need for service)

# of days service is

Review Item

required/wk. (0-7)

(Please indicate the number of days per week each service is required)

1. Tracheotomy Care: All or part of the day

2. Suctioning: Not including routine oral-pharyngeal suctioning, at least once a day

3. IV Therapy: Peripheral or central (not including self-administration)

4. IM/SC Injections: At least once a day (not including self-administration)

5. Pressure Ulcer Care: Stage 3 or 4 and one or more skin treatments (including pressure-

relieving bed, nutrition or hydration intervention, application of dressing and/or medications)

6. Wound Care: Surgical wounds or open lesions with one or more skin treatments per day (e.g.,

application of a dressing and/or medications daily)

7. Tube Feedings: 51% or more of total calories or 500 cc or more per day fluid intake via tube

8. Ventilator Care: Individual would be on a ventilator all or part of the day

9. Complex respiratory services: Excluding aerosol therapy, spirometry, postural drainage or

routine continuous O2 usage

10. Parenteral Feeding or TPN: Necessary for providing main source of nutrition.

11. Catheter Care: Not routine foley

12. Ostomy Care: New

DHMH Form #3871B

Page 2 of 4

Rev 10/11

Medical Eligibility Review Form Page 2

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