Pennsylvania's Office of Long-Term Living uses this two-page certification when a Medical Assistance applicant seeks home and community-based services or Community HealthChoices. The physician lists diagnoses with ICD-10 codes, chooses a level of care (Nursing Facility Clinically Eligible, Nursing Facility Ineligible or ICF/ORC) and states whether the need is long or short term. The signed form goes back to the enrollment broker or assessor for the functional eligibility determination.
The applicant's physician, who must be an MD or DO, completes the whole form: diagnoses, level of care, length of care and signature on page 1, plus the six functional-limitation questions on page 2 when the level of care is ICF/ORC.
Enter the patient's name, address, Social Security number and date of birth at the top of page 1, and repeat the patient's name at the top of page 2. The header notes that the form contains protected health information and warns that providers may not submit false information to obtain authorization to furnish Medical Assistance services or items.
List all diagnoses related to the patient's need for care, each with its ICD-10 code and the diagnosis written out. The form asks you to include diagnoses of brain injury and developmental disability if present. The level-of-care and length-of-care choices that follow rest on these diagnoses, so list every condition that drives the patient's care needs.
Select one level. NFCE means a diagnosed condition causes a need for the care and services of a nursing facility above room and board; NFI means that definition is not met. ICF/ORC means the person requires active treatment and has an ORC diagnosis, a severe chronic disability that began before age 22 and substantially limits at least three major life activities. For individuals 60 or older, choose only between NFCE and NFI.
Indicate the length of care required for the diagnoses you listed. Long term means the condition or disability is anticipated to last 12 months or longer. Short term means it is anticipated to last less than 12 months. The choice should be consistent with the course of the conditions in the diagnosis section.
Print the physician's name, which the form states must be an MD or DO, then the physician license number or Medical Assistance ID number, phone and fax. Sign and date the form. Your signature certifies the diagnoses, level of care and length of care on page 1, and the form makes no provision for a nurse practitioner or physician assistant to sign.
For each of six areas, check Yes or No for a substantial limitation and add comments for every Yes. The form defines each one: self-care means needing significant help with at least half of self-care activities; language means being unable to communicate without a third person or device; mobility means needing another person or device to move about; capacity for independent living means another person is needed more than half of waking hours.
Download the current version from the source each time; forms change without notice.
Physician Certification Form
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Sources for this guide
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No. The physician information block states that the physician must be an MD or DO. The form asks for the physician's name, license number or Medical Assistance ID number, phone and fax, signature and date, so a nurse practitioner or physician assistant cannot certify the level of care on it.
Nursing Facility Clinically Eligible. The form defines it as a person with a physician-diagnosed illness, injury, disability or medical condition who, because of it, needs the level of care and services provided in a nursing facility above the level of room and board. Anyone who doesn't meet that definition is NFI, Nursing Facility Ineligible.
Only when the level of care you selected is ICF/ORC. Page 2 covers six areas: self-care, receptive and expressive language, learning, mobility, self-direction and capacity for independent living. Check Yes or No for a substantial limitation in each area and add comments that substantiate every Yes answer.
The form defines an ORC as a severe chronic disability, other than mental illness or intellectual disability, that began before age 22, is likely to continue indefinitely, impairs general intellectual functioning or adaptive behavior, and causes substantial limits in at least three major life activities. Listed examples include cerebral palsy, spina bifida, epilepsy, severe physical disabilities and autism.