BHSF Form 142 - Louisiana Medicaid Medical Certification

BHSF Form 142 PDF Details

The BHSF Form 142 serves as the official Notice of Medical Certification within the Louisiana Department of Health Medicaid program. It is used for nursing facility and intermediate care facility admissions covered by Louisiana Medicaid.

Purpose of BHSF Form 142

This form documents the medical eligibility determination required before a patient can be admitted to a Medicaid-approved nursing facility in Louisiana. The Bureau of Health Services Financing (BHSF) uses this PDF to confirm that a patient meets the medical criteria for long-term care placement. Without an approved BHSF Form 142, a nursing facility cannot admit a patient under the Louisiana Medicaid program.

Who Completes the Form

The BHSF Form 142 is completed and signed by an Agency Representative from the Office of Aging and Adult Services (OAAS), the Office for Citizens with Developmental Disabilities (OCDD), or the Office of Behavioral Health (OBH), depending on the patient's care needs. The nursing facility or healthcare provider initiates the process by submitting the necessary medical documentation for eligibility review.

Key Form Sections

The form includes sections for initial medical eligibility decisions, Level II authority determinations, waiver and PACE service approvals, provider and facility information, and the Medicaid beneficiary's personal details including Social Security Number and Medicaid ID. Each section must be completed accurately to avoid delays in nursing facility admission approval.

Eligibility and Validity Period

The BHSF Form 142 covers both initial nursing facility admissions and re-evaluations when a patient was not admitted within the approved time frame. Medicaid eligibility determined by this form is tied to the specific nursing facility named in the document. If a patient transfers to a different facility, a new medical certification may be required. For more nursing home documentation, see the Nursing Notes Form.