Fillable NC LTSS-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL (United Health)

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NC LTSS-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL (United Health)

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Alternate Contact (Select One): Parent
Relationship to Member (NON-PCS Provider):
Name:
MI: Last:
RSID#(ACH Only):
Member Name:
MID#:
1
NC LTSS-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
/ /
Form Submission:
Contact UHC C&S North Carolina Provider Call Center at 1-800-638-3302. (toll free).
Expedited Assessment Process Info:
Contact UHC C&S North Carolina Provider Call Center at 1-800-638-3302.
Questions:
Call United HealthCare C&S North Carolina Provider Call Center at 1-800-638-3302.
SECTION A. MEMBER DEMOGRAPHICS
DOB: / /
RSID Date:
/ /
Language:
English
Spanish
Other
_ City: _
Member’s Name: First:
UHC ID#:
Gender:
Male
Female
Address: _
County:
Zip: _ Phone:
( )
Legal Guardian (required if Member < 18) Other
_ Phone: ( )
Active Adult Protective Services Case? Yes No
Member 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. MEMBER’S CONDITIONS THAT RESULT IN NEED FOR ASSISTANCE WITH ADLS
Identify the current
medical diagnoses related to the member'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 ~Member Medically
Stable? Yes No
Is 24-hour caregiver availability required to ensure beneficiary’s safety? Yes No
NC LTSS-3051
FAX: 855-541-8921
Member Name:
MID#:
2 NC LTSS-3051
OPTIONAL ATTESTATION
:
Practitioner should review the following and initial only if applicable:
Member requires an increased level of supervision.
Member 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.
Member requires a physical environment, regardless of setting, that includes modifications and safety
measures
to safeguard the Member because of the member's gradual memory loss, impaired judgment,
disorientation, personality change, difficulty in learning, and the loss of language skills.
Member has a history of safety concerns
related to inappropriate wandering, ingestion, aggressive behavior,
and an increased incidence of falls.
Ini
tial: _______
Initial: _______
Initial: _______
Initial: _______
SECTION C. PRACTITIONER INFORMATION
Attesting Practitioner’s Name: _Practitioner NPI#:
Select one: Member's Primary Care Practitioner Outpatient Specialty Practitioner Inpatient Practitioner
Practice Name: _ NPI#:
Practice Stamp
Practice Contact Name:
Address: _
Phone: ( ) _ Fax: ( )
Date of last visit to Practitioner:
/ /
**
Note:
Must be < 90 days from Received Date
Practitioner Signature AND Credentials: 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 bel
ief. 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):
--- PRACTITIONER FORM ENDS HERE ---
Member Name:
MID#:
3 NC LTSS-3051
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:
Contact UHC C&S North Carolina Provider Call Center at 1-800-638-3302.(toll free).
Questions:
Call UHC C&S North Carolina Provider Call Center at 1-800-638-3302.
MEMBER DEMOGRAPHICS
MI: Last: DOB: / /
Gend
er:
Male
Female Language:
English
Spanish
City:
Other
Member's Name: First:
UHC ID#:
Address: _
County: Zip: _ Phone:
( )
Legal Guardian (required if Member < 18) Other
Alternate Contact (Select One): Parent
Relationship to Member (NON-PCS Provider):
Name:
_ Phone: ( )
Member 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 E: CHANGE OF STATUS: NON-MEDICAL
Requested by
(Select One):
PCS
Provider
Member
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 Member location affects
Other: _ ability to perform ADLs
Describe the specific change in condition and its impact on the member's need for hands on assistance (Required):
SECTION F: CHANGE OF PCS PROVIDER
Other (Relationship): __________________________
Requested by
(Select One): Care Facility Member
Requestor’s Contact
Name:
Phone: ( )
Reason for Provider Change
(Select One):
Member or legal
representative’s choice
Current provider unable to
continue providing services
Other
:
_______________
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.
MEMBER'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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NC LTSS-3051 REQUEST FOR INDEPENDENT ASSESSMENT FOR PERSONAL (United Health)

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Completed 16 April 2022

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