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It includes screening questions on age and service utilization, gathers provider and individual information, records requested service types and hours, and requires complete clinical documentation to support medical necessity.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/prior-authorization-of-increased-state-plan-home-health-services-pa-request-form/288925/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/prior-authorization-of-increased-state-plan-home-health-services-pa-request-form/288925.png","ImageObject",442,249,{"name":42,"@type":43},"Oliver Hayes","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-11","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":22},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"When should this prior authorization form be used?","Question",{"text":62,"@type":63},"Use it when requesting prior authorization for increased State Plan Home Health Services beyond the current State Plan limits.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What happens if the applicant answers “YES” to certain eligibility questions?",{"text":67,"@type":63},"If the individual answers “YES” to any of the listed questions, the request should not be submitted for Increased State Plan Home Health Services.",{"name":69,"@type":60,"acceptedAnswer":70},"What documentation is required to submit with the request?",{"text":71,"@type":63},"Submit, at minimum, a prescription or orders signed by the attending physician, a complete diagnosis list, medical history, level-of-care needs based on medical necessity, and a physician certification of Medical Necessity (JFS 07137), along with waiver or existing service plan details as applicable.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288925,1791696052,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},687207020761,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","PRIOR AUTHORIZATION OF INCREASED STATE PLAN HOME HEALTH SERVICES  \nThis form is to be used when requesting Prior Authorization (PA) for State Plan Home Health Services beyond the current State Plan limits . The individual must be Medicaid fee for service and maybe enrolled in DODD or ODA waivers. The Provider is responsible for verifying the individual’s eligibility at the date of service by viewing the client’s Medicaid Card or verifying eligibility through the portal.  \nPLEASE ANSWER THE FOLLOWING QUESTIONS, CHECK YES IF APPLICABLE:  \nIs the individual less than 21 years old? Yes ☐ No ☐  \nDoes the individual require State Plan Home Health Nursing/Aide services for 14 hours or LESS per week? Yes ☐ No ☐  \nDoes the individual currently use 28 hour or less per week of post hospital benefit? (Up to 60 days) Yes ☐ No ☐  \nDoes the individual currently use 8 hours or less ofState Plan Home Health Nursing/Aide/Therapies? Yes ☐ No ☐  \nIs the individual currently on the Ohio Home Care or Transitional Carve-Out Waiver? Yes ☐ No ☐  \nIs the individual on a managedcare plan? Yes ☐ No ☐  \nIs the service to be used for respite or habilitation? Yes ☐ No ☐  \nSTOP **If you answer YES to any of the questions above, the request should not be submitted for Increased State Plan Home Health Services.  \n**PLEASE DO NOT SUBMIT THE REQUEST**  \n\n| PROVIDER INFORMATION | INDIVIDUAL INFORMATION |\n| --- | --- |\n| Agency Name: | MMIS Number: |\n| Address: | Recipient (patient) Name: |\n| Provider NPI \\#: | Resp. Party (if applicable): |\n| Contact Name: | Relationship: |\n| Phone Number: | Address: |\n| Email (for auth notice): | Email: |\n| Fax: | Fax: |\n| Prescribing Provider Name: | Date Last Seen by Prescribing Provider: |\n| Prescribing Provider NPI \\#: |  |\n\nCase Manager (CM)/Service Support Administrator (SSA) information (If applicable)  \n\n| DODD Waivers:\u003Cbr>☐ I/O ☐ Level 1 ☐ SELF | ODA Waivers:\u003Cbr>☐ PASSPORT ☐ Assisted Living |\n| --- | --- |\n| Name: |  |\n| Phone: |  |\n| Email: |  |\n| Fax: |  |\n\nPlease give a complete description of the services needed. Refer to OAC 5160-12-01 (formerly 5101:3-12-01) for a list of services that will be covered under State Plan Home Health.  \n\n| ☐ Skilled Home Health Nursing RN (G0299)\u003Cbr>☐ Skilled Home Health Nursing LPN (G0300)☐ Home Health Aide (G0156) | Services Requested:\u003Cbr>☐ Physical Therapy (G0151)☐ Occupational Therapy (G0152)\u003Cbr>☐ Speech Therapy (G0153) |\n| --- | --- |\n| Hours per day/ or per week for each service type |  |\n| **If less than weekly; \\# of visits (1 hour=1 visit) per certification period |  |\n| Requested Dates of Service: |  |\n| Principal Diagnosis(es) Code(s): |  |\n\nI affirm all information is a true and accurate description of the above individual. Completed by:    \nDate:    \nLACK OF CLINICAL INFORMATION DELAYS THE PROCESSING OF A PRIOR AUTHORIZATION REQUEST  \nDocumentation Required to be Submitted:  \nAt a minimum, the following documentation must be submitted with the request:  \n☐ Prescription or orders that are signed by the attending physician ☐ Complete diagnosis/es list  \n☐ Medical history  \n☐ Level of care needs based on medical necessity  \n☐ Physician certification of Medical Necessity (JFS 07137) must be included ☐ If the individual is on a waiver, the service plan must be included ☐ If currently receiving any State Plan services , please include:  \n☐ Last 2 weeks of the visit notes  \n☐ Current signed doctor’s orders (485)  \n☐ Nursing assessment (OASIS) completed by RN ☐ All documentation must be legible.  \n☐ Interventions must be consistent with State Plan Home Health rules  \n☐ Interventions must be directly related to the individual’s needs and service plans (if applicable)☐ Information shall be client-specific  \n☐ Information must be detailed  \nPlease return completed form and all required documentation to Permedion by fax at 1-855-474-4306.  \nFOR PERMEDION USE ONLY  \n\n| PA Number | Number of Visits | Number of units | Auth. Start Date | Auth. End Date | CM/SSA notified? |\n| --- | --- |","cbCaitrGOjHou2eQ","https://ap.wps.com/l/cbCaitrGOjHou2eQ","pdf",252121,8,"English","# Provider and Individual Information\n# Eligibility Screening Questions\n# Services Requested and Service Details\n# Documentation Requirements and Submission\n# Permedion Use Only","[{\"question\":\"When should this prior authorization form be used?\",\"answer\":\"Use it when requesting prior authorization for increased State Plan Home Health Services beyond the current State Plan limits.\"},{\"question\":\"What happens if the applicant answers “YES” to certain eligibility questions?\",\"answer\":\"If the individual answers “YES” to any of the listed questions, the request should not be submitted for Increased State Plan Home Health Services.\"},{\"question\":\"What documentation is required to submit with the request?\",\"answer\":\"Submit, at minimum, a prescription or orders signed by the attending physician, a complete diagnosis list, medical history, level-of-care needs based on medical necessity, and a physician certification of Medical Necessity (JFS 07137), along with waiver or existing service plan details as applicable.\"}]","PRIOR AUTHORIZATION OF INCREASED STATE PLAN HOME HEALTH SERVICES - PA Request Form | PDF",1789634231]