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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
Certification of Need: Medicaid Inpatient Psychiatric Services Under Age 21
Recipient Name: Hospital: _______________________
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
Emergency 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 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): 919-328-6011
Eastpointe LME (Duplin, Lenoir, Sampson, and Wayne Counties): 910-298-7184
ValueOptions (All Other Counties): 877-339-8763
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