DMA 3114
[7/1/2016]
Request for Reconsideration of PCS Authorization
North Carolina Department of Health and Human Services – Division of Medical Assistance
Following an initial PCS Service Authorization for less than 80 hours per month, beneficiaries 21 years of age or older,
may submit a Request for Reconsideration of PCS Authorization form to request additional hours. Reconsideration
request must be received no earlier than 31 calendar days and no later than 60 calendar days from the date of the initial
approval notification.
Completed form should be submitted to Liberty Healthcare Corporation-NC via fax to 919-322-5942 or 855-740-0200.
For questions, call 855-740-1400 or 919-322-5944. Incomplete or illegible forms will not be processed.
Section A: Beneficiary Information
Beneficiary Demographics
Name: First: ______________________ MI: ______ Last: __________________ DOB: ____________
Medicaid ID: _________________________ Contact Number: ________________________________
Address (if Different from Initial Request): ________________________________________________
City: _____________________________ County: ____________________ Zip: ____________
Alternate Contact (optional)
Name: First: ______________________________ MI: ______ Last: ____________________________
Relationship to Beneficiary: _______________________________ Phone: _______________________
Section B: Reconsideration
Please specify which ADL(s) and Task(s) are not being supported by the current authorized hours of PCS.
Bathing
Dressing
Mobility
Toileting
Eating
Other – If other, describe
____________________________________________________________________________________
____________________________________________________________________________________
Section C: Supporting Documentation
Supporting documentation must be submitted that specifies, explains, and supports why more authorized hours
of PCS are needed and which ADL(s) and Task(s) are not being met by the current hours. The documentation
should also provide information indicating why the beneficiary believes that the prior assessment did not
accurately reflect the beneficiary’s functional capacity or why the prior determination is otherwise insufficient.
______________________________________________________ ____/____/________
Signature of Medicaid Beneficiary or Legal Guardian/POA Date
_____________________________ ___________________________
Name (Print) Relationship to Beneficiary
