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.
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.
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
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
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
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)
Amount of Services Being Requested
Duration of Services Being Requested (List dates)
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)
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