MEDICAID PERSONAL CARE SERVICES

1. MEDICAID PERSONAL CARE SERVICES PCS Request For Services Form DMA 3051 OVERVIEW & HOW-TOs NC Division of Medical Assistance

2. Module 1: An overview of the current Personal Care Services (PCS) Request for Services form DMA 3051. How to complete the form for New Referrals, Change of Status and Change of Provider requests.

3. MODULE 1: OVERVIEW OF CONSOLIDATED FORM DMA 3051 Personal Care Services (PCS) Request for Services forms have been consolidated into one form as of 10/1/13: PCS Request for Services DMA 3051 All PCS providers, regardless of setting, will use the DMA 3051 form. DMA 3051 is the only form that will allow physicians to provide written attestation to the medical necessity for up to 50 additional PCS hours. Download the current form at: http://info.dhhs.state.nc.us/olm/forms/dma/dma-3051-ia.pdf

4. MODULE 1: OVERVIEW OF FORM DMA 3051 Form DMA 3051 replaced the following forms: As of October 31, 2013 these forms are obsolete.

5. MODULE 1: OVERVIEW OF FORM DMA 3051 10/1/13 Form DMA 3051 Will Now Be Used For These Requests NEW REFERRAL CHANGEOFSTATUS CHANGE OF PROVIDER

6. MODULE 1: COMPLETING PCS FORM DMA 3051 Key Information The terms Beneficiary and Recipient will be used interchangeably throughout the modules. The DMA 3051 form has 6 sections – A through F. You are not required to complete all of the sections of the DMA 3051 form each time you submit the form. Complete only the sections for the specific request being submitted on behalf of the recipient. Refer to the Personal Care Services (PCS) Request for Services Form – DMA 3051 Instructions (effective 10/1/13) available at: http://info.dhhs.state.nc.us/olm/forms/dma/dma-3051-tips.pdf

7. MODULE 1: COMPLETING PCS FORM DMA 3051 NEW REFERRAL

8. MODULE 1: COMPLETING PCS FORM DMA 3051 For NEW Referral Requests, Complete The Following Sections

9. MODULE 1: COMPLETING PCS FORM DMA 3051 New Referral: Section A Required Fields Date of Request Medicaid ID Number – Only active Medicaid participants are eligible. Enter Recipient Name, Date of Birth, Address and Phone. Indicate the recipient’s alternate contacts: parent, guardian or legal representative.

10. MODULE 1: COMPLETING PCS FORM DMA 3051 New Referral: Section B Required Fields Enter the Medical Diagnosis and ICD-9 Code. Enter “O” or “E” for Onset or Exacerbation. Where known, enter the diagnosis date in mm/yyyy format. The date reflects either the date of onset, if it is a new diagnosis, or the date of the most recent exacerbation of a previous diagnosis. Note that the date of onset or exacerbation must be as close to the actual date as possible. If the precise date is unknown, enter 00s in the month and note the year.

11. MODULE 1: COMPLETING PCS FORM DMA 3051 New Referral: Section C Required Fields • Referring Entity Selected: • Indicate if the recipient is medically stable. • Provide Referring Entity’s name, NPI and phone number. • The last visit date must be completed and must have occurred within 90 days of the Request For Services Form submission date. List the date in mm/dd/yyyy format. • The Request For Services Form for the New Referral MUST be signed by the referring entity: an MD/NP/PA. The signature date must be in mm/dd/yyyy format.

12. MODULE 1: COMPLETING PCS FORM DMA 3051 New Referral: Sending The Completed Form Complete Sections A, B & C. Please fax Page 1 of the completed form to: 919-307-8307 or 855-740-1600 (toll free) If you prefer, you may mail Page 1 of the form to: Liberty Healthcare Corporation of NC Attn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606 If you have questions concerning the form, please email NCfax@libertyhealth.com or call 855-740-1400. Keep copies of all forms and fax confirmations for your records.

13. MODULE 1: COMPLETING PCS FORM DMA 3051 New Referral: What Happens Next If the New Referral Request is complete and meets the requirements as outlined in Clinical Coverage Policy 3L, the Referral will be processed and entered into QiRePortwithin 2 business days of receipt. If the information is not complete, the New Referral Request form will be returned by Liberty Healthcare to the referring entity via fax within 2 business days. Liberty Healthcare will verify that the recipient has active Medicaid coverage and the recipient will be contacted by Liberty Healthcare to schedule a Medicaid PCS eligibility assessment. If the recipient is determined to be eligible for PCS, the Provider of Choice will receive the referral via the QiRePort Provider Interface.

14. MODULE 1: COMPLETING PCS FORM DMA 3051 New Requests and PA Effective Dates For new requests, if a beneficiary is awarded PA’s as a result of the assessment, the PA effective date will be the date on the COMPLETED initial request form that was sent to Liberty Healthcare. If a beneficiary requires a PASRR# and the PASRR# becomes effective after the PCS request form was sent to Liberty Healthcare, the PA’s become effective the date the PASRR# becomes effective*. *Requests that require a PASRR will be held by Liberty for 30 days. If a PASRR is not obtained, the request for PCS will be denied.

15. MODULE 1: COMPLETING PCS FORM DMA 3051 New Requests and PA Effective Dates (continued)

16. MODULE 1: TECHNICAL DENIALS • A • Personal Care Services Request for Services may be denied. Unable to Process Missing or Incorrect Information Incomplete Missing Information Complete Non-Qualifying

17. MODULE 1: TECHNICAL DENIALS Recipient Name Recipient Address Medicaid Number Date of Birth Date of request Referring Entity’s name, signature and NPI (National Provider Identifier) Unable to Process Due to Missing Information in Required Fields

18. MODULE 1: TECHNICAL DENIALS No Date of Last Visit to the Referring Entity. Medical stability question is not answered. Medical Diagnosis is not indicated. ICD-9 Code is missing. IncompleteDue to Missing Information in Required Fields

19. MODULE 1: TECHNICAL DENIALS The recipient is not a current Medicaid recipient. The medical stability question is marked “No.” The date of the last visit to the referring entity is more than 90 days from the submission date. Adult recipient is currently receiving private duty nursing or CAP services. CompleteNon-Qualifying

20. MODULE 1: COMPLETING PCS FORM DMA 3051 CHANGEOFSTATUS

21. MODULE 1: COMPLETING PCS FORM DMA 3051 For Change of Status Requests, Complete The Following Sections

22. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Status: Section D Required Fields Select the box that most closely describes the reason for the change in condition. Be sure to include specific changes in condition. Indicate if the recipient is medically stable.

23. When should a change of status be submitted? When there has been a change in: • The recipient’s medical condition • Informal caregiver availability • Environmental condition or location

24. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Status: Sending The Completed Form Complete Sections A, B & D. Please fax Page 1 & 2 of the completed form to: 919-307-8307 or 855-740-1600 (toll-free) If you prefer, you may mail Page 1 & 2 of the form to: Liberty Healthcare Corporation of NC Attn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606 If you have questions concerning the form, please email NCfax@libertyhealth.com or call 855-740-1400. Keep copies of all forms and fax confirmations for your records.

25. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Status: What Happens Next Liberty Healthcare receives the Change of Status Request. All information will be checked for completeness. If all information is complete, the change of status request will be entered into QiRePortwithin 2 business days. If the information is not complete, the change of status request form will be returned to the referring entity via fax within 2 business days.

26. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Status and PA Effective Dates For Change of Status, if a beneficiary is awarded PAs as a result of the assessment, the PA effective date will be 10 days from the date on the notification letter.* PASRR verification is not required for Change of Status requests so this does not impact PA effective dates. *Effective date will not be the date on the Request for Service letter received by the provider.

27. MODULE 1: COMPLETING PCS FORM DMA 3051 CHANGE OF PROVIDER

28. MODULE 1: COMPLETING PCS FORM DMA 3051 For Change of Provider Requests, Complete The Following Sections

29. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Provider: Section F Key Points • A beneficiary may request Change of Provider by submitting this form or by calling Liberty Healthcare. • If a beneficiary needs assistance in selecting an Alternate Preferred Provider, assistance can be provided by a Liberty Healthcare Customer Support Representative. • Liberty Healthcare will confirm all Change of Provider requests with the Beneficiary or legal guardian.

30. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Provider: Section F Required Fields Recipient’s Preferred Provider • Agency Name • Phone • NPI # Contact Information for Questions • Contact’s Name • Phone

31. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Provider: Sending The Completed Form Complete Sections A & F. Please fax Page 1, 2 & 3 of the completed form to: 919-307-8307 or 855-740-1600 (toll-free) If you prefer, you may mail Page 1, 2 & 3 of the form to: Liberty Healthcare Corporation of NC Attn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606 If you have questions concerning the form, please email NCfax@libertyhealth.com or call 855-740-1400. Keep copies of all forms and fax confirmations for your records.

32. MODULE 1: COMPLETING PCS FORM DMA 3051 Change of Provider and PA Effective Dates For a beneficiary who moves from one ACH to another, PAs become effective one day after the date on the notification to the provider. For a beneficiary who receives PCS in home, their PAs become effective with the new provider 10 days from the date on the notification. This allows for communication to be sent to the current provider so they have time to end services and properly discharge the beneficiary from their care. In a scenario where a provider is unable to provide PCS to a beneficiary, all Change of Provider requests will be processed in 1 day and PAs made effective 1 day from the date on the notification.

33. MODULE 1: COMPLETING PCS FORM DMA 3051 New Request vs. Provider?

34. Module 1: Request for Service Accepting or Rejecting the Service Request of a Beneficiary Response to a Request for Service can be executed through QiReport or via fax*. Important Note: Providers are required to obtain a user login to QiRePort so they can manage their beneficiary accounts. For setup of a user login, please call Viebridge at 888-705-0970. Response for service should occur within 2 days of the request. Providers will receive a call from a Liberty Healthcare Coordinator starting on day 3 to follow up on the request response and offer assistance if necessary. If a provider is unresponsive to 3 call attempts from a Liberty Coordinator, then the request will be rejected and submitted to the next provider choice. *Fax option will be ceased in the future due to the requirement for all Providers to utilize the Provider Portal in QiReport.

35. Module 1: Request for Service How to Accept/Reject a Request for Service QiRePort Users: Under the ‘Referrals’ Tab, select ‘Referrals for Review.’ Click here for pending request for service referrals.

36. Module 1: Request for Service How to Accept/Reject a Request for Service (continued): QiRePort Users (continued): When the list populates for beneficiaries with pending requests, click the beneficiary’s name to see the details of their assessment and awarded PA’s. Click here to access a copy of the assessment Provider should select a response to request by selecting the appropriate response decision Hours awarded is displayed here

37. Module 1: Request for Service How to Accept/Reject a Request for Service (continued): Providers Without User Logins for QiRePort: A Request for Service letter will be faxed to the provider along with a copy of the assessment. The provider is to provide a written response and fax the request back to Liberty Healthcare at 919-307-8364.

38. Module 2: An overview of Session Law 2013-306. How to complete the PCS Request for Services form DMA 3051 when additional hours are requested.

39. MODULE 2: AN OVERVIEW OF SESSION LAW 2013-306 Summary of Eligibility Criteria for Additional Hours Per Session Law 2013-306 Increased Caregiving 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 Modified Environment 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. Increased Supervision The recipient requires an increased level of supervision. Increased Safety Concerns The recipient has a history of safety concerns related to inappropriate wandering, ingestion, aggressive behavior, and an increased incidence of falls. The full document can be accessed at: http://www.ncga.state.nc.us/Sessions/2013/Bills/House/PDF/H492v7.pdf

40. MODULE 2: THE REQUEST FOR ADDITIONAL HOURS New Referral*: Requesting up to 80 hours of PCS ANDup to an additional 50 hours * to be completed only if recipient is NOT currently receiving PCS and physician is also requesting up to 50 additional hours

41. MODULE 2: THE REQUEST FOR ADDITIONAL HOURS Section E: New Referrals - Additional Hours Requests • Section E must be completed for all requests of additional hours. • If Section E is NOT completed, Liberty Healthcare will consider this form as a Request for New Referral only.

42. MODULE 2: THE REQUEST FOR ADDITIONAL HOURS New Referrals: Sending The Completed Form Complete Sections A, B, C & E. Please fax Page 1 & 2 of the completed form to: 919-307-8307 or 855-740-1600 (toll-free) If you prefer, you may mail Page 1 & 2 of the form to: Liberty Healthcare Corporation of NC Attn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606 If you have questions concerning the form, please email NCfax@libertyhealth.com or call 855-740-1400. Keep copies of all forms and fax confirmations for your records.

43. MODULE 2: THE REQUEST FOR ADDITIONAL HOURS Current PCS Beneficiaries: Additional Hours Requests For Up To 50 Hours Should Complete The Following Sections

44. MODULE 2: THE REQUEST FOR ADDITIONAL HOURS Current PCS Beneficiaries: Additional Hours Requests Section D Change of Status must be completed. Physicians should check “other” as the reason for the change in Condition Requiring Reassessment. In the Description area, please reference the additional hours mandated by Session Law 2013-306. Section E Physician Attestation must be signed.

45. MODULE 2: the request for ADDITIONAL HOURS Current PCS Beneficiaries: Sending the Completed Form Complete Sections A, B, D & E. Please fax Page 1 & 2 of the completed form to: 919-307-8307 or 855-740-1600 (toll-free) If you prefer, you may mail Page 1 & 2 of the form to: Liberty Healthcare Corporation of NC Attn: Referral Processing Department 5540 Centerview Drive, Suite 114 Raleigh, NC 27606 If you have questions concerning the form, please email NCfax@libertyhealth.com or call 855-740-1400. Keep copies of all forms and fax confirmations for your records.

46. MEDICAID PERSONAL CARE SERVICES CONTACTS Division of Medical Assistance (DMA) PCS Program Phone: 919-855-4340 Fax: 919-715-0102 Email: PCS_Program_Questions@dhhs.nc.gov Liberty Healthcare Corporation of North Carolina Referral/request forms and general inquiries should be addressed to: Liberty Healthcare Corporation-NC PCS Program 5540 Centerview Dr., Suite 114 Raleigh, NC 27606 Call Center Phone: 919-322-5944 or 855-740-1400 (toll free) Fax: 919-307-8307 or 855-740-1600 (toll free) Email: NC-IAsupport@libertyhealth.com Website: www.nc-pcs.com

47. THANK YOU FOR YOUR INTEREST INMEDICAID PERSONAL CARE SERVICES For more information, please visit us at www.nc-pcs.com or call 855-740-1400