Commonwealth of Massachusetts
Executive Office of Health and Human Services

Request and Justification for Continuous Skilled Nursing Services

I.  General Information

Personal Information	

Member’s Name:	

Member’s MassHealth ID Number:	
	
Telephone Number:  (	) 	

Other Insurance Information

MassHealth is the payer of last resort.  The provider should use diligent efforts to obtain coverage from other insurance sources.

Private Insurance Carrier: 	

Policyholder’s Name: 	

Policy Number: 	

Group Number: 	

Why is this service not covered under this insurance? 	

Has this insurance carrier changed since the last prior-authorization request?  	   Yes     No

Household Information

Primary Caregivers:  	  Relationship: 	

                    	 	  Relationship:	

Has there been any change in the member’s status that requires additional training of the primary caregivers?  If so, please be specific.

	

Are there other members in the home who also receive continuous skilled nursing services?  If so, list the names of the members, the number of hours per calendar week, and the home health agency involved.

	

II.  Patient Assessment

Date of Birth:  		Weight:  		Height: 	

Primary Medical Diagnosis: 	

Secondary Medical Diagnoses: 	

Describe in detail the member’s developmental status and ability to perform activities of daily living.

	

	

	

	

	

	

III.  Plan of Care

Provide a plan of care based on a 24-hour-a-day, seven-day calendar week.  List only skilled nursing interventions that require a licensed nurse.  Indicate a specific frequency (not “prn,” “see attached,” or “as needed”).
		
Skilled Intervention	Frequency per Day	

			

			

			

			

			

			

			

Total number of hours requested:    	

IV.  Medications

List all prescription and nonprescription medications that the member takes.  You must document the actual use of PRN medications.  Attach a separate page if you need more space to document all medications.
		
Medication, Dosage, and Route Administered	Frequency/Actual Use	

			

			

V.  Equipment/Supplies

For all items listed below, indicate if they are required in the member’s care.  If equipment or supplies are required, you must indicate the specific type of equipment or supply used.
Equipment	Yes	No	Frequency of Use	
Tracheostomy Tubes					
Suction Machine					
Ventilator (type): 						
Mist					
Oxygen					
Ambu Bag					
Nebulizer					
Gastrostomy Tubes					
Pump/Supplies					
Nasogastric Tubes					
Oxymeter					
Cardiac/Apnea Monitor					
Catheter (type): 						
Ostomy Supplies					
I.V. Equipment (type): 				________________________________	

VI.  Nursing Progress and Summary Notes

If applicable, include an updated summary of the past prior-authorization period.  Document any change in the member’s medical status, including inpatient and/or outpatient hospital visits, frequency of illnesses, changes in plan of care, and calls or visits to the member’s physician.

	

	

VII.  Health-Related Services Currently Provided to the Member

Check all services used by the member.  Indicate the frequency and payer.

Service	Yes	No	Frequency and Payer	
Physical Therapy					
Occupational Therapy					
Speech/Language Therapy					
Intermittent Skilled Nursing Visits					
Home Health Aide					
Personal Care Attendant					
Adult Day Health					
Hospice					
Other:  						

If the member has a third-party insurance, indicate the reason the primary insurer is not covering the services listed in Section VI that are used by the member.  List the name and telephone number of the insurance case manager.

	

VIII.  Services Provided by Other Agencies

If applicable, list services (including respite and case management) that are provided by other sources such as the Massachusetts Commission for the Blind, the Department of Public Health, the Department of Social Services, the Department of Education, the Department of Mental Health, the Department of Mental Retardation, and an early intervention program.  Indicate the frequency of service and the name and telephone number of the case manager.

	

IX.  Request for Continuous Skilled Nursing

Total number of hours per calendar week requested: 	

Current Prior Authorization Number (if applicable):  	  Expiration Date: 	

Number of hours authorized per week: 	

X.  Names and Signatures

Home Health Agency Name:	
Address: 	
Telephone Number: 	

Nurse from Home Health Agency or Independent Nurse
Name:  	 Telephone No.:	(	) 	 
Signature: 	  Date: 	

Physician’s Name:  	 Telephone No.:	(	) 	 
Signature: 	  Date: 	

Primary Caregiver’s Name (optional): 	
Signature: 	  Date: