Verification of eligibility form for medication services under Section 96.02-4(D)

TO:	Private Duty Nursing Services providers
FROM:	Francis T. Finnegan Jr., Director, Bureau of Medical Services
SUBJECT:	Verification of eligibility form for medication services under Section 96.02-4(D) Private Duty Nursing and Personal Care Services, Maine Medical Assistance Manual.
DATE:	May 18, 2000

Attached, please find a template "DMHMRSAS Client Certification for Services" form that shall be required, effective on or after 6/5/00, for recipients who receive medication administration and monitoring services for the treatment of severe and disabling mental illness, pursuant to Section 96 Private Duty Nursing & Personal Care Services.

This form will document an individual’s eligibility for Section 17, Community Support Services, which is a requirement for coverage of the medication services under Section 96. A community support services worker, or a physician, may complete the form, but the physician must certify its accuracy. In addition, under Section 96.02-4(D)(2), the physician must certify a statement, that the patient’s medical condition prevents the safe use of outpatient services and is contraindicated for specific reasons. The reasons must be listed and the likelihood of such a bad result must be probable or definite as opposed to possible or rarely. The expectation is that any patient who can safely and effectively access an outpatient setting for medication services, must do so.

For each new PDN medication services recipient on or after 6/5/00, use the attached Section 17 verification form and maintain it in the recipient’s record. For each currently enrolled PDN medication services recipient, complete the attached Section 17 verification form and maintain it in the recipient’s record.

Anytime a recipient, age 21 and over, who is classified for medication services, also requires any other Section 96 Private Duty Nursing & Personal Care Services, this will trigger a medical eligibility assessment and prior authorization by the Assessing Services Agency (ASA). The Section 17 verification form must be submitted to Goold Health Systems, the ASA, when requesting prior authorization for services.

Finally, signed and dated copies of the form must be maintained by the PDN provider in the recipient’s record. A signed and dated form shall be valid for up to 12 months, then a new classification period must be established. Recipients may be classified for services under Section 96.02-4(D) up to 12 months, then a new classification period must be established. This form may be downloaded from the BEAS Website at www.state.me.us/dhs/beas/pdn/pdn.htm.

If you have any questions regarding this notice, please contact your Provider Relations Specialist at 287-3094 or 1-800-321-5557, Option 1. (For TTY call 287-1828 or 1-800-423-4331.)

FTF/jct

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