Ohio Odm 02374 Form Modify Form Here

Ohio Odm 02374 Form

The Ohio ODM 02374 form is a request for Private Duty Nursing (PDN) services, used by providers to obtain prior authorization from Medicaid. This form ensures that consumers receive the necessary nursing care while adhering to eligibility requirements. Accurate completion of the form is essential to avoid automatic denial of requests.

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Table of Contents

The Ohio ODM 02374 form plays a crucial role in the process of requesting private duty nursing (PDN) services for Medicaid recipients. This form is essential for ensuring that individuals receive the appropriate level of care based on their medical needs. It requires detailed consumer information, including the individual’s name, Medicaid number, and date of birth, as well as the name and contact information of the provider submitting the request. Providers must ensure that the consumer is eligible for Medicaid on the date of service to prevent automatic denial of the prior authorization request. Additionally, the form includes sections for case manager information and approval from the Ohio Department of Medicaid, which is necessary for service delivery. In cases where services are needed beyond the standard 60-day post-hospital benefit, a physician's letter must accompany the request, detailing the medical necessity for increased hours. The form also allows for changes in services, whether increasing, decreasing, or terminating them, with appropriate justification required. Proper completion and submission of the ODM 02374 form are vital for facilitating access to necessary nursing care for individuals in need.

Form Sample

Ohio Department of0HGLFDLG

PRIVATE DUTY NURSING (PDN) SERVICES REQUEST

INITIAL

RECERTIFICATION

CHANGE

Medicaid will automatically deny Prior Authorization (PA) Requests for clients who are not Medicaid eligible on the date of service. To avoid this, providers must determine consumer eligibility before requesting prior authorization.

CONSUMER INFORMATION (Complete entirely for all requests.)

Consumer Name (First, MI, Last)

Date of Request

Street Address

 

City

 

 

State

Zip Code

 

 

 

 

 

 

 

 

Phone Number (Area Code and Number)

 

 

County of Residence

 

 

 

 

 

 

 

 

 

Medicaid Number (12 digits)

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

 

 

 

Name of Parent or Guardian

 

 

 

Phone Number(s)

 

 

 

 

 

 

 

 

 

Waiver Type (Check)

 

 

 

 

 

 

 

ODA-Administered Waiver

DODD-Administered Waiver

No Waiver

 

I am requesting to receive private duty nursing services. I have authorized this case manager or provider to submit this request as written. I authorized 0HGLFDLG, the case manager, and the provider listed below, or the ODA-Administered or DODD-Administered Waiver case manager to exchange protected health information related to the assessment for and provision of private duty nursing services contained within this request.

 

Consumer’s or Authorized Representative’s Signature

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDER INFORMATION (Complete entirely for all requests.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Name (First, MI, Last)/Agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Phone Number

Fax Number

 

Email Address

 

 

 

 

 

 

 

 

 

 

Ohio Medicaid Provider Number 7 digits (Required)

National Provider Identifier Number

Nursing License Number

 

 

 

 

 

 

 

 

 

 

 

The individual submitting this form certifies that the information provided is true, accurate, and complete. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal or State funds may be prosecuted under Federal or State laws.

ODA OR DODD CASE MANAGER INFORMATION

(Request MUST be submitted to 0HGLFDLGby the CASE MANAGER if receiving ODA-Administered or DODD –Administered waiver services.)

 

Case Manager Name

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

 

Fax Number

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

Medicaid APPROVAL (For State use only)

 

 

 

 

 

PDN Services Approved

 

Number of Base and Sub Units Per Day, and Number of Hours Authorized Per Week

 

YES

NO

 

 

 

 

 

 

Scope of Services Approved

 

 

 

 

 

 

 

 

 

 

 

 

Duration of Services Approved

 

 

 

 

 

 

From

To

 

 

 

 

 

 

 

 

 

ODJFS Approved By

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

Additional Comments

 

 

 

 

 

 

NOTE: Prior approval by 0HGLFDLG only authorizes service delivery. It does not guarantee a consumer’s Medicaid eligibility It is the provider’s responsibility to check a consumer’s Medicaid eligibility each month.

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)RUPHUO\JFS 02374 (Rev. 8/2012)3age 1 of 2

REQUEST FOR PDN SERVICES BEYOND THE 60-DAY POST-HOSPITAL STATE PLAN BENEFIT

The consumer’s attending physician identifies the need for PDN beyond what the State Plan 60 day Private Duty Nursing Post Hospital Benefit provides. An agency or independent provider must be found and agree to take care of the consumer. The request for PDN services must come from the provider or case manager if consumer is enrolled on an ODA-Administered or DODD-Administered waiver. A signed letter must be obtained from the physician that substantiates the need for the increased PDN hours and sent with the PDN request form. The letter must contain at minimum the following:

The current diagnosis and the history of the illness

The projected date of hospital discharge

The estimated amount, frequency and duration of the services

The expected skilled, continuous nursing interventions with the frequency of those interventions specified.

A temporary prior authorization number may be issued for a limited time until a face to face assessment can be completed.

NOTIFICATION OF PROVISION OF EMERGENCY SERVICES (Complete for recertification requests only.)

Pursuant to OAC 5101:3-12-02.3(E)(1) PDN services may be delivered in an emergency and a new PDN authorization obtained after the delivery of services. The PDN services must be medically necessary in accordance with OAC 5101:3-1-01 and the services must be necessary to protect the health and welfare of the consumer. (Emergency services are provided outside normal State of Ohio office hours when prior approval cannot be obtained.) Notification must be submitted no later than the first business day following service provision.

List Emergency Services Provided

Reason for Emergency

Number of Units of Service Provided Per Day

Number of Days of Service Provided Per Week

Consumer Name

Medicaid Number

REQUEST FOR CHANGE IN SERVICES (INCREASE, DECREASE, TERMINATION, WITHDRAWAL)*

(Complete for recertification requests only.)

Amount of Services Currently Being Received

Duration of Services Currently Being Received (List dates)

 

From

To

Amount of Services Being Requested

Duration of Services Being Requested (List dates)

 

From

To

Reason for Request (If increase, please include justification for increase with supporting documentation (Physician orders, visit notes, increased skilled nursing interventions, 485, etc)

*The individual submitting this form certifies that the information provided is true, accurate, and complete. Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal or State funds may be prosecuted under Federal or State laws.

Independent and Agency Providers

This form must be submitted via the Medicaid MITS Web Portal:

http://medicaid.ohio.gov/providers/mits.aspx

No faxes or emails will be accepted for PDN requests.

For DODD Service Coordinators and PASSPORT Case Managers ONLY

Email or fax the completed form to:

Ohio Department of 0HGLFDLG Bureau of Long Term Care Services and Supports

EMAIL: pdn_bcsp@PHGLFDLG.ohio.gov FAX: 614-387-7661

If questions call: 614-466-6742

ODM 02374 (7/2014)

 

Formerly JFS 02374 (Rev. 8/2012)

Page 2 of 2

Form Information

Fact Name Description
Form Title This form is titled "Private Duty Nursing (PDN) Services Request." It is used for initial requests, recertifications, and changes.
Governing Law The form is governed by Ohio Administrative Code (OAC) 5101:3-12-02.3 and OAC 5101:3-1-01.
Eligibility Requirement Medicaid will deny prior authorization requests if the consumer is not eligible on the service date.
Consumer Information All consumer details must be filled out completely, including name, address, and Medicaid number.
Provider Information Providers must provide their name, address, contact information, and Medicaid provider number.
Signature Requirement The consumer or authorized representative must sign the form, confirming the accuracy of the information.
Emergency Services Emergency PDN services can be provided without prior approval, but must be reported by the next business day.
Change Requests Changes in services, such as increases or decreases, require justification and supporting documentation.
Submission Method The form must be submitted through the Medicaid MITS Web Portal; faxes or emails are not accepted.
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