Free Ohio Odm 02374 Template

How to Use Ohio Odm 02374

Filling out the Ohio Department of Medicaid (ODM) 02374 form is an important step for those seeking Private Duty Nursing (PDN) services, either for the first time or as a recertification. Careful attention to detail is crucial throughout this process to ensure that the request is processed smoothly and efficiently. The form requires precise consumer and provider information, details about the requested PDN services, and appropriate authorizations. Here's how to fill it out step by step.

1. Under CONSUMER INFORMATION, fill in the consumer's full name, date of the request, complete address, phone number, county of residence, Medicaid number, date of birth, and, if applicable, the name and phone number of a parent or guardian. Check the applicable waiver type.
2. Ensure the consumer or their authorized representative signs and dates the form after reading the section about authorizing the exchange of protected health information related to PDN services.
3. In the PROVIDER INFORMATION section, enter the provider or agency's full name, address, phone and fax numbers, email address, Ohio Medicaid provider number, National Provider Identifier number, and nursing license number.
4. If applicable, fill out the ODA OR DODD CASE MANAGER INFORMATION section, including the case manager's name, phone and fax numbers, and email address. This section is mandatory if the consumer is receiving ODA-Administered or DODD-Administered waiver services.
5. If this request is part of a recertification that includes a request for change in services, complete the section labelled REQUEST FOR CHANGE IN SERVICES (INCREASE, DECREASE, TERMINATION, WITHDRAWAL). Specify the current and requested amount and duration of services, and provide a detailed reason for the request. Supporting documentation should be attached as indicated.
6. For initial requests beyond the 60-day post-hospital State Plan benefit, attach a letter from the consumer’s attending physician outlining the need for extended PDN hours. This should include the diagnosis, history, projected hospital discharge date, estimated service amount, frequency, duration, and expected skilled nursing interventions.
7. Independent and Agency Providers must submit this form via the Medicaid MITS Web Portal as indicated. No fax or email submissions will be accepted.
8. For DODD Service Coordinators and PASSPORT Case Managers, email or fax the completed form to the specified contacts. Direct any questions to the provided phone number.

After submission, it's the provider's responsibility to verify the consumer's Medicaid eligibility each month to prevent service interruptions. Keeping a copy of the submitted form for your records is advised. Timely and accurate completion and submission of the ODM 02374 form is a crucial step towards acquiring necessary PDN services.

What is the Ohio ODM 02374 form used for?

The Ohio ODM 02374 form is designed to request Private Duty Nursing (PDN) Services under the Ohio Department of Medicaid. It covers initial requests, recertification, and changes in service levels for Medicaid clients who require private nursing services either following a hospital stay beyond the 60-day State Plan Benefit or as part of their ongoing care needs. It's a critical tool for clients, their case managers, or providers to secure prior authorization for PDN services to ensure that the client receives the necessary care while also verifying Medicaid eligibility.

Who needs to complete the ODM 02374 form?

This form must be completed by a case manager or a provider who is submitting the request on behalf of a Medicaid consumer in need of PDN services. For consumers receiving ODA-Administered or DODD-Administered waiver services, the request must be submitted to Ohio Medicaid by the case manager. It is also incumbent upon providers to ensure the form is accurately and fully completed to prevent any delays in the authorization process.

Can the Ohio ODM 02374 form be submitted electronically?

Yes, the Ohio ODM 02374 form must be submitted through the Medicaid MITS Web Portal for independent and agency providers, ensuring a more streamlined and secure submission process. However, for DODD Service Coordinators and PASSPORT Case Managers, the completed form can be sent via email or fax to the specified contacts at the Ohio Department of Medicaid. This process is in place to ensure that submissions are handled efficiently and within Medicaid's operational standards.

What happens if a consumer is not Medicaid eligible on the date of service?

Medicaid will automatically deny Prior Authorization (PA) Requests for clients who are not Medicaid eligible on the date of service. It is critical for providers to verify the consumer's Medicaid eligibility before submitting a request for PDN services to avoid unnecessary denials. This emphasizes the importance of conducting eligibility checks each month to ensure uninterrupted service provision and compliance with Medicaid's requirements.

What information is required from the attending physician for PDN services request?

A request for PDN services beyond the 60-day Post-Hospital State Plan Benefit requires a detailed letter from the consumer's attending physician. This letter must include the current diagnosis, the history of the illness, the projected date of hospital discharge, the estimated amount, frequency, and duration of the needed services, and the expected skilled, continuous nursing interventions required. This ensures a comprehensive assessment of the consumer's needs to support the PDN service request.

How are emergency PDN services handled?

In cases where PDN services are urgently required outside normal State of Ohio office hours and prior approval cannot be obtained, services may be delivered on an emergency basis. Providers must submit notification of the provision of such emergency services no later than the first business day following service provision. This is to ensure that services delivered during emergencies are recognized, accounted for, and considered in the context of the consumer's overall care plan.

Is there a specified process for requesting changes in PDN services?

For recertification requests that include changes in services, such as increases, decreases, termination, or withdrawal, the relevant section of the form must be completed in detail. This includes listing the current amount and duration of services being received, the requested changes to these services, and the justification for this request with supporting documentation. It mandates a thorough and justified approach to modifying a consumer's care plan, ensuring that changes in PDN services are well-founded and appropriately authorized.

Filling out the Ohio Department of Medicaid's ODM 02374 form for Private Duty Nursing (PDN) Services can sometimes be tricky. When handling this important document, people often make mistakes that can easily be avoided. Being mindful of these common errors can save time and help ensure the request is processed smoothly. Here’s a breakdown of the nine most common mistakes:

1. Not checking Medicaid eligibility before applying: The form clearly states that Medicaid will automatically deny Prior Authorization Requests for clients not eligible on the date of service. Always verify the consumer's eligibility first.

2. Incomplete consumer information: Every field in the CONSUMER INFORMATION section should be filled out entirely. Leaving fields blank or providing incomplete information can result in delays or denials.

3. Incorrect Medicaid number entry: The Medicaid number should be 12 digits. Providing an incorrect number, whether through typographical errors or illegibility, can lead to processing delays.

4. Leaving out provider details: Just like consumer information, PROVIDER INFORMATION must be fully completed. This includes the 7-digit Ohio Medicaid Provider Number, which is often overlooked.

5. Missing signatures: The form requires signatures from the consumer or authorized representative and the individual submitting the form. Missing signatures will result in automatic denial.

6. Forgetting to include the physician’s letter for PDN services beyond the 60-day Post-Hospital State Plan Benefit: This letter is crucial for justifying the need for extended PDN services and must meet specific criteria listed on the form.

7. Not specifying the emergency services provided: For recertification requests involving emergency services, detailed information about the services and the reason for the emergency must be included.

8. Failing to detail the request for change in services: If requesting an increase, decrease, termination, or withdrawal of services, the form asks for existing and requested service amounts and durations, along with a reason for the request.

9. Improper submission method: The form emphasizes that Independent and Agency Providers must submit via the Medicaid MITS Web Portal, while DODD Service Coordinators and PASSPORT Case Managers may email or fax the form. Using an incorrect submission method will result in the form not being processed.

Avoiding these mistakes can considerably streamline the process for requesting PDN services, helping to ensure that those in need receive the care they require without unnecessary obstacles.

When dealing with Ohio's Department of Medicaid, particularly for requests related to Private Duty Nursing (PDN) services as outlined in the ODM 02374 form, it’s not uncommon to need several other forms and documents. These documents play crucial roles in ensuring that all necessary information and approvals are in place for the administration of PDN services. This list provides an overview of additional forms and documents often needed alongside the Ohio ODM 02374 form to facilitate a smoother process for all involved.

• Physician Certification Statement (PCS): Required for some Medicaid services to substantiate the medical necessity and appropriateness of the services being requested. It includes detailed information about the patient’s condition and the medical services needed.
• ODM 01907: Ohio Medicaid Consumer Guide: This document helps consumers understand Medicaid services, including eligibility and the process to apply for benefits like PDN. It's essential for patients and their families to comprehend the coverage and responsibilities.
• ODM 9401: Prior Authorization (PA) Request Form: Used to request prior approval for specific services not automatically covered under Medicaid. This form is necessary for services that require review to confirm they are medically necessary.
• Letter from Attending Physician: A detailed letter from the consumer's doctor, providing a comprehensive medical history, current condition, projected needs, and justification for the PDN services beyond what is typically covered. This letter supports the PDN request form.
• Medicaid Consumer’s Proof of Eligibility: Document or electronic verification confirming the consumer's eligibility for Medicaid. Verification of eligibility is a prerequisite for the approval of PDN services to ensure that the state will cover the costs.
• Care Plan or Service Plan: Developed by a case manager or a healthcare provider, this plan outlines the specific services, frequency, and duration that the consumer needs. For PDN, it details the nursing interventions required to meet the consumer’s healthcare needs.

Together, these documents complement the ODM 02374 form by providing a comprehensive picture of the consumer's health status, the medical necessity for PDN, and ensuring all administrative boxes are checked for Medicaid coverage. Whether seeking initial certification, recertification, or a change in PDN services, possessing the correct documentation streamlines the process, making it easier for consumers to receive the care they need.

The Ohio Odm 02374 form is closely related to the Home Health Care Certification and Plan of Care Form (CMS-485). Both forms serve the essential function of documenting the need for specific healthcare services at the patient's home, ensuring they meet the criteria to receive those services under their health coverage. The CMS-485 form is used by Medicare for certifying a patient's eligibility for home health services and outlines the plan of care prescribed by the attending physician, similar to how the ODM 02374 form documents the need for private duty nursing (PDN) and the detailed plan of care, including services' duration and frequency.

Another similar document is the Prior Authorization Request Form utilized by various insurance providers, including Medicaid in different states. These forms are essential for obtaining pre-approval before delivering certain healthcare services to ensure coverage. Like the ODM 02374, prior authorization forms require detailed patient information, provider details, and a specific medical justification for the requested service, emphasizing the patient's current health status and the necessity of the proposed treatment or service.

The Individual Service Plan (ISP) used in the administration of waiver programs, including those for developmental disabilities and aging (such as the ODA and DODD waivers mentioned in the ODM 02374), mirrors this form in its purpose and content. ISPs are comprehensive documents that outline the services a consumer requires based on an assessment of their needs. Similarly, the ODM 02374 aims to establish the need for PDN services as part of the patient's broader care plan, requiring detailed information about the consumer's condition, desired outcomes, and service parameters.

The Medicaid Eligibility Verification Form, while more general in its application, shares some similarities with the ODM 02374 form. This eligibility form is crucial for determining a patient's qualification for Medicaid benefits at the outset of care or service provision. Both documents require accurate consumer information including Medicaid number, and highlight the importance of verifying eligibility as a prerequisite for service approval and coverage. The ODM 02374 specifically instructs providers to ensure Medicaid eligibility before requesting prior authorization, reinforcing this common requirement.

Lastly, the Emergency Medical Services (EMS) Certification of Medical Necessity Form parallels the ODM 02374 form in certain respects. This form is typically used to document the medical necessity for emergency or non-emergency transportation services covered by Medicare, Medicaid, or other insurers. Similar to sections of the ODM 02374 that deal with emergency PDN services, the EMS form requires detailed patient information, a certification of necessity signed by the attending physician, and an explanation of the services provided, emphasizing the necessity and urgency of the care.

When filling out the Ohio ODM 02374 form for Private Duty Nursing (PDN) Services Request, there are crucial steps to follow and pitfalls to avoid. Here's a guide to help ensure a smooth process.

• Verify Medicaid Eligibility: Before submitting the request, confirm that the consumer is eligible for Medicaid on the intended date of service. This prevents automatic denials due to ineligibility.
• Complete All Required Sections: Ensure every part of the form is filled out entirely, including consumer and provider information. Incomplete forms can lead to delays or rejections.
• Include Accurate Information: The data provided must be true, accurate, and complete. Misrepresentation can lead to prosecution.
• Obtain Necessary Signatures: The form requires signatures from the consumer or their authorized representative to process the request. Ensure all signatures are obtained as specified.
• Follow Submission Guidelines: Submit the form via the Medicaid MITS Web Portal for providers. DODD Service Coordinators and PASSPORT Case Managers should use the designated email or fax.
• Attach Supporting Documents: When requesting PDN services beyond the 60-day post-hospital benefit, include a letter from the attending physician that supports the need for additional services.
• Check for Updates: Always use the most recent version of the form to ensure compliance with current requirements.
• Keep Records: Maintain a copy of the submitted form and any correspondence for future reference.

• Assume Eligibility: Never presume a consumer is Medicaid eligible without verification. Eligibility status can change, impacting authorization.
• Use Outdated Forms: Submitting an outdated version of the form can lead to processing delays or denials. Always verify you are using the correct and current form.
• Skip Sections: Avoid leaving sections incomplete unless specified. This can cause the request to be incomplete.
• Forget Signatures: Missing signatures can invalidate the request. Ensure all required parties have signed before submission.
• Ignore Guidelines: Failing to follow the exact submission guidelines, such as using fax or email when not permitted, can result in the rejection of the request.
• Overlook Supporting Evidence: Not attaching required supporting documents, such as the physician’s letter for extended PDN services, can hinder the approval process.
• Miss Deadlines: Late submissions, especially for recertification or change requests, can interrupt services to the consumer.
• Misrepresent Information: Providing false or misleading information not only risks prosecution but can jeopardize the consumer's care.

There are several misconceptions about the Ohio ODM 02374 form, which is pivotal for requesting private duty nursing (PDN) services. Clarifying these misunderstandings can help ensure that individuals and providers navigate the process more effectively.

• Misconception 1: Medicaid eligibility is automatically checked when you submit the ODM 02374 form.

  In reality, it is the provider's responsibility to verify Medicaid eligibility each month, as prior authorization only concerns service delivery.

• Misconception 2: The ODM 02374 form is only for initial requests for PDN services.

  However, the form is used for initial requests, recertification of services, and any changes, such as increases or decreases in service amount.

• Misconception 3: Any healthcare provider can submit the ODM 02374 form directly.

  In fact, submissions must be made through the Medicaid MITS Web Portal for independent and agency providers, and through email or fax for DODD Service Coordinators and PASSPORT Case Managers.

• Misconception 4: Physician's letters providing background on the patient’s need aren't necessary unless it's a recertification request.

  Contrary to this belief, a signed letter from the physician is required even for initial requests if the PDN services needed exceed the 60-day post-hospital State Plan benefit, outlining the medical necessity for increased hours.

• Misconception 5: Emergency PDN services don't require authorization.

  While emergency PDN services can be delivered without prior authorization, notification must be submitted no later than the first business day following the provision of emergency services.

• Misconception 6: The form encompasses all necessary information for Medicaid approval.

  It's crucial to understand that aside from this form, additional documentation may be required for a comprehensive assessment, including medical records or further justification for the requested services.

• Misconception 7: Once approved, PDN services are guaranteed for the duration specified.

  Approval only indicates that services are authorized to be delivered; it doesn't guarantee the patient's Medicaid eligibility nor the availability of a provider to deliver said services throughout the entire period.

Understanding the Ohio ODM 02374 form fully can help streamline the request process for PDN services, ensuring that necessary support is provided to those in need without undue delays or issues.

• Before submitting the Ohio Department of Medicaid (ODM) 02374 form for Private Duty Nursing (PDN) services, providers must confirm the patient's Medicaid eligibility to avoid automatic denial of the Prior Authorization (PA) Requests for services on dates when the patient is not eligible.
• The form can be submitted for various purposes, including initial requests for PDN services, recertification, or changes in the current PDN services, such as adjustments in the hours or scope of services.
• All sections of the consumer information must be fully completed, including personal details, Medicaid number, and type of waiver, if applicable. This ensures that the request is processed accurately and efficiently.
• Consent is crucial; the form requires a signature from the consumer or authorized representative, granting permission for their medical information to be shared among the Medicaid, case manager, and the PDN service provider.
• Provider information, including contact details, Medicaid provider number, and nursing license number, should be accurately filled to facilitate smooth communication and processing.
• In cases where the PDN services are beyond the 60-day Post-Hospital State Plan Benefit, additional documentation from the attending physician substantiating the need for extended PDN hours must accompany the form.
• For recertification or when requesting changes in services, detailed justifications and relevant documentation supporting the need for adjustment in services are essential for approval.
• Submissions of the ODM 02374 form are specific to the medium based on the provider type; independent and agency providers are directed to use the Medicaid MITS Web Portal, while DODD Service Coordinators and PASSPORT Case Managers may email or fax their submissions to the designated contacts.