Fillable DHB-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE (North Carolina)

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DHB-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE (North Carolina)

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7/1/2021
D
HB-3051 I
These instructions offer guidance for completing the Request for Independent Assessment and Attestation of
Medical Need Form for Personal Care Services (PCS) and should be read in its entirety before completing.
Expedited Assessment Process Info: Contact Liberty Healthcare Corporation at 1-855-740-1400. Questions:
Call or Email Liberty Healthcare at 855-740-1400, 919-322-5944, or
nc-iasupport@libertyhealth.com.
DHB-3051
REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES
ATTESTATION OF MEDICAL NEED
INSTRUCTIONS
Personal Care Services (PCS) is a Medicaid benefit based on the need for assistance with Activities of
Daily Living (ADLs). The ADLs are bathing, dressing, toileting, eating, and transferring/functional mobility in
the home. The purpose of the Request for Independent Assessment / Attestation of Medical Need Form
(DHB-3051) is to request a PCS Independent Assessment. Requested assessments will be one of the
following: Disenrollment, New Request, Change of Status (Medical or Non-Medical), or Change of Provider.
Sections A – E: Change of Status: Medical, New Request, and Managed Care Disenrollment (located on
pg. 1-2 of the form) shall be completed by a practitioner with section E completed by the PCS Provider if for
Managed Care Disenrollment.
Request Type: Select the type that indicates the reason for the request. Enter the Date of
Request in the appropriate field.
Section A: Beneficiary’s Demographics. The beneficiary’s name should be the same as it
appears on their Medicaid card. Beneficiaries living in, and those seeking admission to, an
Adult Care Home (ACH) will have the facility’s address and phone number. If identified as
legal guardian or Power of Attorney (POA), submit guardianship/POA documents to Liberty
Healthcare.
*The RSID # and RSID Date is generated when a beneficiary, being referred or seeking admission to
an ACH, is referred to a LME-MCO for the RSVP. Further information can be found below, pg 2.
The Alternate Contact should not be a PCS Provider.
Section B: Beneficiary’s Conditions. Enter information regarding current medical conditions that
limit the beneficiary’s ability to perform, and resulted in a need for assistance with, ADLs.
Medical Diagnosis and ICD-10 Code are both required fields.
The Diagnosis and ICD-10 entered must relate to the ADL deficit for this request to be processed.
Optional Attestation: This step is optional. Review each statement and initial, only if applicable.
Section C: Practitioner Information. Enter Practitioner and Practice information in the
appropriate field. You may use the practice stamp if applicable. Sign and date once completed.
Signature stamps are not allowed.
Section D: Change of Status: Medical. Complete if requesting a Medical Change of Status.
Describe the medical change and it’s impact on the beneficiary’s need for hands on assistance.
Section D, located on page 2, is a required field for all Medical Change of Status Requests. The
date of the beneficiary’s last PCP visit must be < 90 days from Received Date by the IAE.
It is required that the beneficiary’s PCP or inpatient practitioner complete this form. If beneficiary
does not have a PCP, the practitioner, currently providing care and treatment for the medical,
physical or cognitive condition causing the functional limitation, may complete the form.
Section E: Managed Care Disenrollment: Medical. Complete if requesting disenrollment from
Managed Care. Enter the information regarding the beneficiary’s current plan, date of
enrollment, effective date of disenrollment, current approved PCS hours, and current PCS
provider. Completed form should be faxed to Liberty Healthcare prior to disenrollment date.
--- PRACTITIONER FORM ENDS HERE ---
Step 7
7/1/2021
D
HB-3051 I
Sections F – G: Non-Medical Change of Status and Change of Provider Requests, located on pg. 3 of
the form, shall be completed by the beneficiary, family member, legal guardian, home care provider, or
residential provider.
Request Type. Select the Request Type that indicates the reason for the request. Enter the Date
of Request in the appropriate field.
Beneficiary’s Demographics. The beneficiary’s name should be the same as it appears on
their Medicaid card. For Beneficiaries living in, and those seeking admission to, an ACH,
enter the facility’s address and phone number.
The Alternate Contact should not be a PCS Provider.
Section F: Change of Status: Non-Medical. Complete if requesting a Non-Medical Change
of Status. Enter the Facility License # and Date, if applicable. Describe the specific change
in condition and its impact on the beneficiary’s need for hands on assistance.
Section F, found on pg 3, is a required field for all Non-Medical Change of Status Requests.
Section G: Change of PCS Provider. Complete if requesting a Change of Provider.
**Note: Effective 11/1/2018 any Medicaid beneficiary referred to or seeking admission to Adult Care Homes (ACH)
licensed under G.S. 131D-2.4 must be referred to a LME-MCO for the Referral Screening Verification Process
(RSVP). Adult Care Home providers licensed under G.S. 131D-2.4 shall not receive a PCS assessment or prior
approval without verification of a Referral Screening ID (RSID). If you have questions about your status in this
process, please contact the Division of Mental Health at 919-981-2580.
Completed Request Forms should be submitted to Liberty Healthcare Corporation-NC via fax
at 919-307-8307 or 855-740-1600 (toll free).
Beneficiary Name:
MID#:
DHB-3051
7/1/2021
DHB-3051
REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE SERVICES (PCS)
ATTESTATION OF MEDICAL NEED
MEDICAL CHANGE OF STATUS OR NEW REQUESTS, PRACTITIONERS COMPLETE PAGES 1 & 2 ONLY
REQUEST TYPE:
(select one)
DATE OF REQUEST:
Change of Status: Medical
New Request
Managed Care
Disenrollment
___/ /____
Form Submission:
Fax Liberty Healthcare Corporation-NC at 919-307-8307 or 855-740-1600 (toll free).
Expedited Assessment Process Info:
Contact Liberty Healthcare Corporation at 1-855-740-1400.
Questions:
Call Liberty Healthcare at 855-740-1400 or 919-322-5944.
SECTION A. BENEFICIARY DEMOGRAPHICS
Beneficiary’s Name: First:
MI: Last:
DOB: / /
Medicaid ID#:
RSID#(ACH Only):
RSID Date:
/ /
Gender:
Male
Female Language:
English
Spanish
Other
Address: City:
County: Zip: Phone: ( )
Alternate Contact (Select One): Parent Legal Guardian (required if beneficiary < 18) Other
Relationship to Beneficiary (NON-PCS Provider):
Name: _ Phone: ( )
Active Adult Protective Services Case? Yes No
Beneficiary currently resides:
At home
Adult Care Home
Hospitalized/medical facility
Skilled Nursing Facility
Group Home
Special Care Unit (SCU)
Other D/C Date (Hospital/SNF): / /
SECTION B. BENEFICIARY’S CONDITIONS THAT RESULT IN NEED FOR ASSISTANCE WITH ADLS
Identify the current
medical diagnoses related to the beneficiary’s need for assistance with
qualifying Activities of Daily Living
(bathing, dressing, mobility, toileting, and eating). List both the diagnosis and the COMPLETE ICD-10 Code.
Medical Diagnosis
ICD-10
Code
Impacts
ADLs
Date of Onset
(mm/yyyy)
1.
_ _ _ . _ _ _ _
Yes
No
2.
_ _ _ . _ _ _ _
Yes
No
3.
_ _ _ . _ _ _ _
Yes
No
4.
_ _ _ . _ _ _ _
Yes
No
5.
_ _ _ . _ _ _ _
Yes
No
6.
_ _ _ . _ _ _ _
Yes
No
7.
_ _ _ . _ _ _ _
Yes
No
8.
_ _ _ . _ _ _ _
Yes
No
9.
_ _ _ . _ _ _ _
Yes
No
10.
_ _ _ . _ _ _ _
Yes
No
In your clinical judgment, ADL limitations are:
Short Term (3 Months)
Intermediate (6 Months)
Age Appropriate
Expected to resolve or improve (with or without treatment) Chronic and stable
Is Beneficiary Medically Stable?
Yes No
Is 24-hour caregiver availability required to ensure beneficiary’s safety? Yes No
Beneficiary Name:
MID#:
DHB-3051
7/1/2021
2
OPTIONAL ATTESTATION
:
Practitioner should review the following and initial only if applicable:
Beneficiary requires an increased level of supervision.
Beneficiary requires caregivers with training or experience
in caring for individuals who have a
degenerative disease, characterized by irreversible memory dysfunction, that attacks the brain and results in
impaired memory, thinking, and behavior, including gradual memory loss, impaired judgment, disorientation,
personality change, difficulty in learning, and the loss of language skills.
Beneficiary requires a physical environment, regardless of setting, that includes modifications and safety
measures
to safeguard the beneficiary because of the beneficiary's gradual memory loss, impaired judgment,
disorientation, personality change, difficulty in learning, and the loss of language skills.
Beneficiary has a history of safety concerns
related to inappropriate wandering, ingestion, aggressive
behavior, and an increased incidence of falls.
Initial:
Initial:
Initial:
Initial:
SECTION C. PRACTITIONER INFORMATION
Attesting Practitioner’s Name: _Practitioner NPI#:
Select one: Beneficiary’s Primary Care Practitioner Outpatient Specialty Practitioner Inpatient Practitioner
Practice Name: _ N P I #:
Practice Stamp
Practice Contact Name:
Address: _
Phone: ( ) _ Fax: ( )
Date of last visit to Practitioner:
/ /
**
Note:
Must be < 90 days from Received Date
: : / /
*Signature stamp not allowed*
“I hereby attest that the information contained herein is current, complete, and accurate to the best of my knowledge and belief. I
understand that my attestation may result in the provision of services which are paid for by state and federal funds and I also understand
that whoever knowingly and willfully makes or causes to be made a false statement or representation may be prosecuted
under the applicable federal and state laws.”
SECTION D. CHANGE OF STATUS: MEDICAL Complete for medical change of status request only.
Describe the specific medical change in condition and its impact on the beneficiary’s need for hands on assistance (Required):
SECTION E: Managed Care Disenrollment
Disenrolling from; Plan name (Select One): AmeriHealth Caritas NC, Inc. Carolina Complete Health, Inc.
Blue Cross Blue Shield of NC, Inc. UnitedHealthcare of NC, Inc. WellCare of NC, Inc.
Disenrollment Effective Date: _____/_____/____ Current PCS Hours: ________
BENEFICIARY’S CURRENT PROVIDER)
Agency Name: Phone: ( )
Provider NPI#: Provider Locator Code# _______
Facility License # (if applicable): Date: / /
Physical Address:
Practitioner Signature AND Credentials
Date
Step 7
click to sign
signature
click to edit
Beneficiary Name:
MID#:
DHB-3051
7/1/2021
3
NON
--
‐
MEDICAL CHANGE OF STATUS OR CHANGE OF PROVIDER REQUESTS, COMPLETE PAGE 3 ONLY
REQUEST TYPE:
(select one)
DATE OF REQUEST:
Change of Status: Non-Medical
Change of Provider
/ /
Form Submission:
Fax Liberty Healthcare Corporation-NC at 919-307-8307 or 855-740-1600 (toll free).
Questions:
Call Liberty Healthcare at 855-740-1400 or 919-322-5944.
BENEFICIARY DEMOGRAPHICS
Beneficiary’s Name: First: MI: Last: DOB: / /
Medicaid ID#:
Gender:
Male
Female Language:
English
Spanish Address:
City:
Other County:
Zip: Phone: ( )
Alternate Contact (Select One): Parent Legal Guardian (required if beneficiary < 18) Other
Relationship to Beneficiary (NON-PCS Provider):
Name: _ Phone: ( )
Beneficiary currently resides:
At home
Adult Care Home
Hospitalized/medical facility
Skilled Nursing Facility
Group Home
Special Care Unit (SCU)
Other D/C Date (Hospital/SNF): / /
SECTION F: CHANGE OF STATUS: NON-MEDICAL
Requested by
(Select
One):
PCS
Provider
Beneficiary
Legal
Guardian
Power of
Attorney (POA)
Responsible
Party
Family (Relationship):
_
Requestor Name:
PCS Provider NPI#: PCS Provider Locator Code#
__________
Facility License # (if applicable): Date: / /
Contact’s Name: Contact’s Position:
Provider Phone: ( ) Provider Fax: ( ) Email:
Reason for Change in Condition Requiring Reassessment
(Select One): Change in Days of Need Change in Caregiver Status Change in Beneficiary location affects
Other: _ ability to perform ADLs
Describe the specific change in condition and its impact on the beneficiary’s need for hands on assistance (Required):
SECTION G: CHANGE OF PCS PROVIDER
Requested by (Select One):
Care Facility
Beneficiary
Other (Relationship): _
Requestor’s Contact Name: Phone: ( )
Status of PCS Services
(Select One):
Discharged/Transferred Scheduled Discharge/Transfer No Discharge/Transfer Planned.
Date: / / Date: / / Continue receiving services until established with a new provider.
BENEFICIARY’S PREFERRED PROVIDER
(Select One):
Home Care
Agency
Family Care
Home
Adult Care
Home
Adult Care Bed in Nursing
Facility
SLF-
5600a
SLF-
5600c
Special Care
Unit
Agency Name: Phone: ( ) Provider
NPI#: Provider Locator Code# _______
Facility License # (if applicable): Date: / /
Physical Address:
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DHB-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL CARE (North Carolina)

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Completed 16 April 2022

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