Billing Manual for Nursing Facility Services Section. a. Form DMA-59 is mailed to the appropriate Department of Family and b. Forms DMA-295 and DMA-296 are mailed to the fiscal agent. XI-3 APPENDIX A Medicaid Member Identification Card Sample A-1 PeachCare for Kids Member A-2 You may request a Provider Enrollment Application/enrollment documents or submit inquiries by one of the methods listed below Mail ACS Post Office Box 4000 Phone 800 766-445.
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How to fill out the DMA 59 online
Filling out the DMA 59 form online can seem daunting, but this user-friendly guide will walk you through each step. This form is essential for nursing facilities and intermediate care facilities, ensuring that the necessary authorizations for Medicaid are completed effectively and accurately.
Follow the steps to complete the DMA 59 online.
- Click the ‘Get Form’ button to obtain the DMA 59 form and open it in the online editor.
- In Section I, enter the provider’s name and location. Include the Medicaid provider number and recipient's social security number. Ensure the recipient's name and Medicaid ID are correctly formatted.
- Fill in the recipient's primary and secondary diagnosis codes, along with the date of birth. Indicate the admission date and prior location for the patient.
- Complete Section II for initial admissions, specifying the recommended level of care based on the DMA-6 form, and mark the admission date and location prior to the facility.
- For status changes, complete Section III including the new level of care and effective date.
- If terminating services, complete Section IV by indicating the reason for termination and the date, along with the destination of the recipient.
- Finalize by signing Section V with the facility administrator’s signature and date.
- Review all fields for accuracy and ensure all required sections are filled out completely before submission.
Complete your DMA 59 form online today to ensure smooth processing of nursing facility reimbursement.
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