ARKANSAS DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL SERVICES
REQUEST FOR PRIVATE DUTY NURSING SERVICES PRIOR AUTHORIZATION & PRESCRIPTION
INITIAL REQUEST OR RECERTIFICATION
Section I.
PATIENT’S LAST NAME (1)
PHONE NUMBER (6)
FIRST (2)
MIDDLE (3)
COUNTY RESIDENCE (7)
SEX (4)
DATE OF BIRTH
(8)
Patient’s Medicaid ID # (5)
M
F
SOCIAL SECURITY # (9)
(
)
MAILING ADDRESS (Street, City, State and Zip Code) (10)
RESIDENCE ADDRESS (Street, City, State and Zip Code) (11)
PARENT/GUARDIAN NAME: (12)
CAREGIVER NAME: (13)
Child Screening Referral (14)
INSURANCE COMPANY AND ADDRESS (15)
Yes
No
Provider Name and Address, Phone & Fax # (17)
Primary Diagnosis code & brief description (19)
ICD
Date of Home Evaluation by Private Duty
Nursing Agency or Explanation of Why
Incomplete. (22)
INSURANCE POLICY NUMBER (16)
Provider ID Number/Taxonomy Code (18)
Secondary Diagnosis (20)
Date of Home Evaluation by DME provider
or Explanation of Why Incomplete. (23)
Other Diagnosis (21)
Date of Emergency Plan Established by
Private Duty Nursing Agency or
Explanation of Why Incomplete (24)
Section II
Item (25)
Please attach a current medical & surgical history that includes M.D. summary, prognosis medical followup requirements. Include changes since last certification if recertification.
Item (26)
Current Services Required for Patient Management.
Ventilator-Dependent
IV Drugs (chemotherapy, pain relief or prolonged IV antibiotics)
Respiratory - Tracheostomy Care Or Oxygen supplementation
Total care support for ADL’s and close patient monitoring
Hyperalimentation - parenteral or enteral
Item (27)
Anticipated beginning date of service__________________________________________________
DMS-2692 (Rev. 12/15/14)
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Section II (Continued):
Item (28)
Justification of need for shift nursing: _____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Item (29)
Short Term Goals: _____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Item (30)
Long Term Goals: (must include plan for reduction of hours) ___________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Item (31)
Physical Therapy (frequency, treatment & goals): ____________________________________
_________________________________________________________________________________________________
Item (32)
Occupational Therapy (frequency, treatment & goals): ________________________________
_________________________________________________________________________________________________
Item (33)
Speech Therapy (frequency, treatment & goals): _____________________________________
_________________________________________________________________________________________________
Item (34)
Additional Services (ex: Personal Care, Early Intervention, Developmental Day Treatment
Clinic Mental Health, Home Health, Name of Targeted Case Manager): ___________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Item (35)
Equipment or Special Physical Aids (How and Where Used?) Note if equipment no longer used
or needed ______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
DMS-2692 (Rev. 12/15/14)
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Section II (Continued)
Item (36)
Medications - Route & Frequency: ________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Item (37)
Daycare/School Days & Hours (Where & by Whom?) ________________________________
__________________________________________________________________________________________
Item (38)
Hospitalizations in last year - Reason and Length of Stay: ______________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Item (39)
Patient/Family Education: _______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Section III:
Item (40)
A.
Psycho-Social History: Please include changes in psycho-social situation since last certification
if recertification.
Caregiver’s understanding of client’s condition: ____________________________________________
__________________________________________________________________________________________
B.
Family composition: __________________________________________________________________
__________________________________________________________________________________________
C.
Primary caregivers: ___________________________________________________________________
__________________________________________________________________________________________
D.
Support system: ______________________________________________________________________
__________________________________________________________________________________________
E.
Community support: __________________________________________________________________
__________________________________________________________________________________________
F.
Identified stressors: ___________________________________________________________________
__________________________________________________________________________________________
G.
Financial status: ______________________________________________________________________
__________________________________________________________________________________________
H.
Transportation Requirements: ___________________________________________________________
__________________________________________________________________________________________
DMS-2692 (Rev. 12/15/14)
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Section III (Continued)
I.
Number of competent caregivers in home (name & relationship to client): _______________________
__________________________________________________________________________________________
J.
Do caregivers work? (If so, give work schedule): ___________________________________________
__________________________________________________________________________________________
K.
Specify hours & days family cares for the client: ____________________________________________
__________________________________________________________________________________________
L.
Specify hours & days agency cares for the client: ___________________________________________
__________________________________________________________________________________________
Section IV:
Prescription of Care:
Item (41)
Level of Nursing Care Requested by Agency: _______________________________________
Procedure Code for R.N. or L.P.N.
Item (42)
Frequency of care to be provided by agency __________hours X _________days per week.
Item (43)
On recertification, note hours currently approved: ____________________________________
__________________________________________________________________________________________
Section V:
Primary Care Physician’s Certification: (44)
I certify that the above named patient can be treated in a home setting with the services specified in this plan of care. Are
services appropriate for the condition of the patient? Yes___________ No ___________.
Are Home/Community resources available for this plan of care? Yes____________ No _____________.
Is shift nursing medically necessary? Yes_____________ No_____________
Date Last Examined
Signature of PCP_______________________________________________
Date____________________________
Address___________________________________________________________________________________________
City, State and Zip Code______________________________________________________________________________
PCP Provider ID Number/Taxonomy Code:_______________________________________________________________
DMS-2692 (Rev. 12/15/14)
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Section VI:
Item (45)
Appropriateness of Care:
TO BE COMPLETED BY DIVISION OF MEDICAL SERVICES
The care plan submitted on the above patient has been reviewed. Based on the evidence submitted, our decision is that the
plan of care (assessment) is appropriate to the needs of the patient: Yes______ No______
Level of Nursing Care Authorized_______________________________________________________________
(RN or LPN)
Frequency of Care Authorized_________________________ hours x________________ days per week.
(1 hr. = 1 unit)
Signature of Nurse ____________________________________________ Date _________________________________
Reason for denial or reduction in hours: _________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________
Signature of Medical Director
Date
Item (46) Prior Authorization #: To be completed by the Division of Medical Services.
1) _______________________________________
4) ___________________________________
2) _______________________________________
5) ___________________________________
3) _______________________________________
6) ___________________________________
MAIL FORM TO:
Division of Medical Services
Utilization Review Section
P.O. Box 1437, Slot S413
Little Rock, AR 72203-1437
NEW CASES MUST BE SENT AS SOON AS POSSIBLE PRIOR TO DISCHARGE.
THE FIRST REVIEW WILL BE IN THREE MONTHS. SUBSEQUENT REVIEWS WILL BE EVERY SIX MONTHS,
HOWEVER, IF PROBLEMS ARE IDENTIFIED, A SPECIAL REVIEW MAY BE REQUESTED.
COMPLETED INFORMATION MUST BE SENT TO THE ABOVE ADDRESS ONE MONTH PRIOR TO REVIEW
DATE FOR ONGOING CASES.
FORM DMS-2692 MAY BE OBTAINED BY COMPLETING A MEDICAID FORM REQUEST AND MAILING TO:
PROVIDER ASSISTANCE CENTER
HEWLETT PACKARD ENTERPRISE
P.O. BOX 8036
LITTLE ROCK, AR 72203-8036
If you need this material in an alternative format, such as large print, please contact the Program Development and Quality
Assurance Unit at 501-320-6429.
DMS-2692 (Rev. 12/15/14)
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Completion of Private Duty Nursing Services Request for Prior Authorization and Prescription
Initial Request or Recertification (Form DMS-2692)
BENEFICIARY AND PROVIDER DATA – To be completed by provider.
Patient’s Last Name: Enter the patient’s last name.
Patient’s First Name: Enter the patient’s first name.
Middle Initial: Enter the patient’s middle initial.
Sex: Check “M” for Male, “F” for Female.
Patient’s Medicaid I.D. Number: Enter the Patient’s I.D. number. This entry will be
a ten-digit number.
Item 6 Home Phone Number: Enter patient’s area code and phone number.
Item 7 County of Residence: Enter the county in which the patient resides.
Item 8 Date of Birth: Enter the patient’s month, day and year of birth. (MM/DD/YYYY)
Item 9 Social Security Number: Enter patient’s social security number.
Item 10 Mailing Address: Enter the patient’s mailing address. Include 9-digit zip code.
Item 11 Residential Address: Enter patient’s residential address.
Item 12 Parent/Guardian Name: Enter the patient’s parent(s) or guardians last name, first
name and middle initial or Non-applicable.
Item 13 Caregiver Name: Enter the patient’s primary caregiver’s last name, first name and
middle initial (if different from Item 12).
Item 14 If services were rendered as a result of the beneficiary having had an EPSDT
screen check the “yes” box. Otherwise check “no.”
Item 15 Insurance Company and Address: Enter name and address of patient’s insurance
company.
Item 16 Insurance Policy Number: Enter patient’s insurance policy number.
Item 17 Provider Name, Address, Phone Number and Fax Number: Enter name of provider
of nursing services, address, phone number and fax number.
Item 18 Provider ID Number/Taxonomy Code: Enter provider’s identification number and
taxonomy code.
Item 19 Primary Diagnosis Code and Brief Description: Enter patient’s primary diagnosis
and ICD Diagnosis Code.
Item 20 Secondary Diagnosis: Enter patient’s secondary diagnosis and ICD Diagnosis
Code.
Item 21 Other Diagnosis: Enter patient’s other diagnosis and ICD Diagnosis Code.
Item 22 Date of Home Evaluation by Private Duty Nursing Agency or Explanation of Why
Incomplete: Prior to the patient’s hospital discharge the agency must complete an
evaluation of the patient’s home. Enter the date of the home evaluation
(MM/DD/YYYY). If incomplete, give explanation.
Item 23 Date of Home Evaluation by DME provider or Explanation of Why Incomplete: Prior
to the patient’s hospital discharge the provider must complete an evaluation of the
patient’s home. Enter the date of the home evaluation (MM/DD/YYYY).
Item 24 Date Emergency Plan Established by Private Duty Nursing Agency or Explanation of
Why Incomplete: Prior to the patient’s hospital discharge the agency must establish
an emergency plan for the patient. Enter the date the emergency plan was
established (MM/DD/YYYY). If incomplete, give explanation.
SECTION II: CURRENT SERVICES REQUIRED FOR PATIENT MANAGEMENT
Item 25 Current Medical and Surgical History: Attach a MD summary including prognosis
and medical follow-up requirements. Include changes since last certification if
recertification.
SECTION I:
Item 1
Item 2
Item 3
Item 4
Item 5
Item 26 Current Services Required for Patient Management: Check the appropriate
services.
Item 27 Anticipated Beginning Date of Service: Enter date that is anticipated to be the
beginning date of service (MM/DD/YYYY).
Item 28 Justification of Need for Shift Nursing: Give information related to the patient’s
condition that necessitates shift nursing.
Item 29 Short Term Goals: List short term nursing goals for the patient.
Item 30 Long Term Goals: List long term nursing goals for the patient. Must include a plan
for reduction of total number of shift nursing hours.
Item 31 Physical Therapy (frequency, treatment and goals): Describe the frequency,
treatment and goals of P.T. that patient’s condition will require or enter nonapplicable.
Item 32 Occupational Therapy (frequency, treatment and goals): describe the frequency,
treatment and goals of O.T. that patient’s condition will require or enter nonapplicable.
Item 33 Speech Therapy (frequency, treatment and goals): Describe the frequency,
treatment and goals of S.T. that patient’s condition will require or enter nonapplicable.
Item 34 Additional Services (ex: Personal Care Early Intervention, Developmental Day
Treatment Clinic Services, Mental Health, Home Health, Targeted Case
Management): List each service currently received by the patient, level of care,
frequency and duration.
Item 35 Equipment or Special Physical Aids: List all of patient’s equipment or special
physical aids, and how and where it is used. Note if equipment no longer used or
needed.
Item 36 Medication: List all medication taken by the patient. Include route and frequency.
Item 37 Daycare/School Hours: Give hours/day and days/week client is in a Day
care/school setting or Developmental Day Treatment Clinic. Non-applicable can
only be used for clients over age 21.
Item 38 Hospitalizations in last year: List each hospitalization for patient in the last year.
Include reason for admission and length of stay.
Item 39 Patient/Family Education: List the medical training that patient and/or family has
completed.
SECTION III: TO BE COMPLETED BY PRIVATE DUTY NURSING AGENCY
Item 40 Psycho-Social History: Please include changes in psycho-social situation since last
certification if recertification.
a. Caregiver’s understanding of client’s condition - Describe caregiver’s
understanding of client’s condition.
b. Family Composition - Describe family composition.
c. Primary Caregivers - List primary caregivers.
d. Support System - Describe family’s support system.
e. Community Support - Describe family’s community support.
f.
Identified Stressors - Give identified stressors.
g. Financial Status - Give family’s financial status.
h. Transportation Requirements - Describe client’s transportation requirements.
i.
Number of competent caregivers in home - Give name and relationship to client
of all competent caregivers in the home.
j.
Do caregivers work? If caregivers work, give work schedule.
k. Specify hours and days family cares for the client.
l.
Specify hours and days agency cares for the client.
SECTION IV: PRESCRIPTION OF CARE
Item 41 Level of Nursing Care Requested by Agency: List procedure code for RN or
procedure code for LPN.
Item 42 Frequency of Care to be Provided by Agency: Fill in number of hours/day and
number of days/per week, e.g. 5 hrs/day X 5 days/wk.
Item 43 On Recertifications, note hours currently approved.
SECTION V: PHYSICIAN’S CERTIFICATION
Item 44 Primary Care Physician’s Certification: The patient’s PCP certifies:
a. Whether the patient can be treated in a home setting with the services specified
in the plan of care.
b. Whether services are appropriate for the patient’s condition.
c. Whether home/community resources are available for the plan of care.
d. Whether shift nursing is medically necessary.
e. Give PCP’s name, address, city, state, 9-digit zip code, provider identification
number, taxonomy code, and date of signature.
SECTION VI:
Item 45 Appropriateness of Care: To be completed by Division of Medical Services RN and
Medical Director.
Item 46 Prior Authorization Number: To be completed by Division of Medical Services. The
prior authorization control number will be entered by the Division of Medical
Services. The prior authorization control number must be entered on the Medicaid
claim form filed for payment of Private Duty Nursing Services.