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

Form Preview Example

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

How to Edit BHFS Form 142 Online for Free

Making use of the online tool for PDF editing by FormsPal, you'll be able to fill out or edit form 142 nursing home right here and now. Our development team is ceaselessly endeavoring to develop the tool and help it become much easier for users with its handy functions. Unlock an constantly innovative experience now - take a look at and find out new possibilities as you go! Here's what you would need to do to begin:

Step 1: Click on the "Get Form" button in the top area of this page to open our tool.

Step 2: With this advanced PDF editor, it is possible to accomplish more than just fill in blanks. Edit away and make your documents appear faultless with custom text added in, or optimize the file's original content to excellence - all that supported by an ability to add stunning pictures and sign the PDF off.

When it comes to blank fields of this particular form, this is what you should consider:

1. When filling in the form 142 nursing home, be sure to complete all essential blank fields in their associated area. This will help speed up the process, making it possible for your information to be processed quickly and appropriately.

Step number 1 in submitting what is a 142 form used for nursing home placement

2. The third step is usually to fill out these particular blanks: C Not ApprovedDenied Does not, D ICFDD decision pendingadditional, Date, Agency Representative, OCDDOAAS Office Address II, If item F G or H is marked, E Level II decision is not required, through, F Approved for admission by Level, G Approved for admission by Level, H Not Approved Admission Denied, Agency Representative, OCDDOBH Office Address, III WAIVERPACE, and Date.

what is a 142 form used for nursing home placement writing process described (portion 2)

3. In this particular step, take a look at Agency RepresentativeSupport, Date, OAAS or OCDD Regional Office or, OAAS or OCDD Regional Office or, FacilityProvider Medicaid Long, Office of Behavioral Health, OAAS, and OCDD. Every one of these need to be completed with greatest accuracy.

Simple tips to prepare what is a 142 form used for nursing home placement part 3

Lots of people frequently make mistakes when filling out OAAS or OCDD Regional Office or in this section. You should reread what you enter right here.

Step 3: After taking one more look at your entries, press "Done" and you are good to go! Right after registering a7-day free trial account here, it will be possible to download form 142 nursing home or send it via email directly. The file will also be at your disposal through your personal account page with your each change. At FormsPal, we do our utmost to make sure that all your details are kept protected.