What Are You Attesting To When You Sign A Medicaid Personal Care Services (PCS) Request For Services Form?As the medical provider for your Medicaid patient, you're asked to fill out and sign the Medicaid's Personal Care Services (PCS) DMA 3051 form for the New Referral Request section and, if appropriate for your patient, the Request for Additional Hours section. Each section requires your signature. So, what are you signing and what exactly are you attesting to when you do?
You're Requesting Hands-On Assistance For Your Patient
When you request personal care services for your patient, you're asking North Carolina's Medicaid agency to assess your patient for his or her need for hands-on assistance by a paraprofessional aide with Activities of Daily Living (ADLs). The State of North Carolina recognizes the following five (5) ADLs: (1) Bathing, (2) Dressing, (3) Mobility, (4) Toileting, (5) Eating. A nurse assessor will then meet with your patient to determine your patient's eligibility for this program. If your patient is eligible, then he or she may receive up to 80 hours per month of hands-on assistance by a paraprofessional aide.
What You're Attesting To On A New Referral Request
The New Referral Request asks you to list the current medical diagnoses that currently limit the patient's ability to independently perform Activities of Daily Living , prepare meals, and manage medications. The form also asks you if your patient is medically stable and the date of your patient's last visit to you. You need to have seen your patient within the last 90 days of your filling out this form.
What you are attesting to by signing Section C of the Request For Referral Form is that the information that you've filled out in sections A, B and C of the form is accurate for your patient. Your dated signature also authorizes Liberty Healthcare of North Carolina to conduct a PCS eligibility requirement.
What You're Attesting To On A Request For Additional Hours
If you feel that it's a medical necessity that your patient needs to receive more than 80 hours per month of hands-on assistance by a paraprofessional aide, then you would complete the Optional Attestation Section of the DMA 3051 form.
Session Law 2013-306 requires that a physician attest that the recipient meets each of the criteria below to be eligible for up to 50 additional hours of PCS as determined through the independent assessment.
- The recipient requires an increased level of supervision.
- The recipient 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.
- Regardless of setting, the recipient requires a physical environment that includes modifications and safety measures to safeguard the recipient because of the recipient's gradual memory loss, impaired judgment, disorientation, personality change, difficulty in learning, and the loss of language skills.
- The recipient has a history of safety concerns related to inappropriate wandering, ingestion, aggressive behavior, and an increased incidence of falls.
What you are attesting to by signing Section C of the Request For Referral Form is that the information that you've filled out in sections A, B, and C, (D if applicable) of the form is accurate for your patient. Your dated signature also authorizes Liberty Healthcare of North Carolina to conduct a PCS eligibility requirement for up to 50 additional hours per month.
For any questions concerning the DMA 3051, please contact Liberty Customer Support at 1-919-322-5944 or 1-855-740-1400 .