Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin with Section I — Provider Information. This section requires you to provide details about the billing provider. Fill in the name of the billing provider, their National Provider Identifier, and Taxonomy Code, ensuring that all required fields marked with an asterisk are completed.
3. Next, continue filling out the billing provider’s address, which includes the street address, city, state, and ZIP+4 code. Additionally, provide the billing provider’s Medicaid provider number.
4. In this section, also provide the name and telephone number of the nursing home contact person for any necessary follow-up.
5. Proceed to Section II — Member Information. Start by selecting whether this is a new request or a revised start date. This is crucial as it helps in categorizing your request accurately.
6. Fill in the member's name, member identification number, Social Security number, date of birth, and gender. These fields are essential for identifying the individual requiring care.
7. Indicate the requested start date for nursing home authorization and provide the nursing home discharge date if applicable.
8. If applicable, select whether an MDS Admission Assessment will be submitted to the CMS MDS system. This is important for processing the care determination.
9. If an MDS admission assessment will not be submitted, you are required to attach specific documents: physician's orders admitting the member to the nursing home, all nursing medical notes, and the discharge summary.
10. Once all sections are completed, review the form for accuracy. Ensure that all required fields are filled out correctly.
11. Finally, save your changes in the online editor. You can download, print, or share the completed form as needed.

Start filling out your Request For Nursing Home Care Determination online today to ensure timely access to care.