BHFS Form 142 PDF Details

An overview of the BHSF Form 142 reveals its pivotal role within the Louisiana Department of Health and Hospitals' Medicaid Program. Designed as a Notice of Medical Certification, this form encompasses several critical functions aimed at facilitating the intersection of healthcare provision and Medicaid eligibility determinations. Its structured format offers a thorough procedure for assessing individuals' eligibility for nursing facility admissions or intermediate care facilities, distinguishing between medical and financial eligibility with clarity. With sections dedicated to initial decisions on medical eligibility, potential Level II authority interventions for more nuanced cases, and specific resolutions around waiver services, the form ensures a comprehensive evaluation process. It necessitates detailed provider information, including the vendor number and the facility address, alongside the personal information of the Medicaid beneficiary, such as their Social Security Number and Medicaid ID, ensuring a personalized and accurate assessment. Moreover, the form takes into account the dynamic nature of patients' needs and Medicaid's regulatory environment by incorporating provisions for temporary periods of eligibility and re-evaluation in cases of non-admission within designated time frames. Thus, the BHSF Form 142 stands as a crucial administrative tool, striving to streamline the often complex navigation through Medicaid's eligibility criteria while prioritizing the well-being and proper care of beneficiaries.

QuestionAnswer
Form Name BHFS Form 142
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names lousiana 142 form for nursing home, what is a 142 form used for nursing home placement, louisiana form 142 for nursing home placement, 142 form

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BHSF FORM 142 REV. 07/12

PRIOR ISSUE OBSOLETE

Louisiana Department of Health and Hospitals

Medicaid Program

Notice of Medical Certification

SSN:

Date of Birth:

 

Medicaid No:

To:

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

 

 

 

Facility/Provider/Support Coordinator Name:

 

 

 

 

 

Vendor No:

 

Facility Address:

 

 

 

 

 

Parish:

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Facility or Intermediate Care Facility

•Eligibility must be approved prior to admission to Nursing Facility. Prior approval is valid for 30 days for Nursing Facility Admission. If admitted within 30 days, decision is valid until discharged. If not admitted within 30 days of decision, a new decision is needed.

•This decision relates to medical eligibility only and is separate from a decision on financial eligibility for Medicaid.

I.

A. Approved for Medicaid/Private medical eligibility services effective

 

.

 

 

 

 

 

 

 

 

 

 

 

 

Level II decision pending.

 

 

Level of Care:

 

 

 

 

B. Approved for Medicaid medical eligibility services for a temporary period effective

 

 

 

 

through

 

.

Level of Care:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check:

 

 

 

 

 

 

 

 

 

MD/Physician involvement

 

 

TDC

 

 

 

Treatment/Conditions

 

 

NRTP

 

 

 

Skilled Therapies

 

 

Other:______________________

 

 

 

Hospital Exemption

 

 

 

 

 

 

 

 

C. Not Approved/Denied – Does not meet Medicaid medical eligibility requirement.

D. ICF/DD decision pending-additional information needed:

Agency Representative

 

Date:

 

 

 

 

OCDD/OAAS Office Address

II. If item F, G, or H is marked, disregard Section I decision.

E.

Level II decision is not required.

 

 

 

 

 

 

 

 

F.

Approved for admission by Level II Authority effective

 

 

 

 

 

 

 

 

.

G.

Approved for admission by Level II Authority for a temporary period effective

 

through

.

H.

Not Approved – Admission Denied by Level II Authority.

 

 

 

 

 

 

 

 

Agency Representative

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCDD/OBH Office Address

 

 

 

 

 

 

 

 

 

III. WAIVER/PACE

 

 

 

 

 

 

 

 

A.

Approved Medicaid waiver criteria for

 

 

Waiver services effective

 

.

B.

Not Approved - Does not meet Medicaid medical eligibility.

 

 

 

 

 

 

 

 

C.

Vendor Payment May Begin Date:

 

 

 

 

 

 

 

 

 

Agency Representative/Support Coordinator:

 

Date:

 

 

 

 

 

 

OAAS or OCDD Regional Office or OBH State Office:

 

 

 

 

OAAS or OCDD Regional Office or OBH State Office Address:

 

 

 

CC:

Facility/Provider

Office of Behavioral Health

Medicaid Long Term Care Unit (specify Parish):

Other (specify):

OAAS

OCDD

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