Ohio Medicaid covers home health aide, nursing and therapy visits and private duty nursing only when they are certified as medically necessary, and this is the form for that certification. The qualifying treating physician completes the section that fits: home health without a related hospital stay, home health after a covered stay, or post-hospital PDN, and certifies the face-to-face encounter. The agency keeps it and uses it for PDN prior authorization.
Only the qualifying treating physician may certify medical necessity and sign. The face-to-face encounter may be conducted by the physician, a collaborating advanced practice nurse or a physician assistant under the physician's supervision, whose name and credentials go on the form.
Each page starts with the individual's name and Medicaid billing number and the qualifying treating physician's name and billing number. The opening note explains that the form certifies home health (Section I or II) and private duty nursing (Section III) under OAC 5160-12, documents the face-to-face encounter, and is never a level of care determination for waivers or institutional admission.
Home health aide, intermittent nursing and skilled therapies are covered only part-time or intermittently: no more than 8 combined hours a day, 14 hours a week of nursing and aide services, and visits of 4 hours or less, with exceptions in OAC 5160-12 for people under 21 or hours prior authorized by ODM. PDN is continuous RN or LPN care in visits longer than 4 hours and up to 12 hours per nurse in a day.
Check the boxes that apply: the individual needs medically necessary home health unrelated to an inpatient stay; or, for someone under 21, needs increased home health services; and you, a collaborating advanced practice nurse or a supervised physician assistant conducted and documented a face-to-face encounter within the allowed window. Record who conducted the encounter and the encounter date, then sign and date.
Check that the individual was discharged from an inpatient stay of three or more days and give the discharge date. Certify that the person needs home health nursing or a skilled therapy at least once a week and that you ordered it, and certify the face-to-face encounter. Then certify an institutional-comparable level of care, either through waiver enrollment or the criteria listed below it.
The criteria are: hands-on help with at least two ADLs; hands-on help with one ADL plus inability to self-administer needed medications; 24-hour awake supervision due to cognitive impairment; specific developmental or functional criteria by age group (under five, six through 15, 16 and older); or skilled nursing 7 days a week or therapy 5 days a week because an unstable condition needs constant monitoring and the care is complex or has special complications.
PDN here is up to 56 hours a week, certified for up to 60 consecutive days after discharge from a covered stay of three or more consecutive overnights. Check the discharge box and date, then certify a skilled level of care: at least one skilled nursing service 7 days a week or PT, OT or speech therapy 5 days a week, ordered because of instability plus complexity or special complications. Sign and date.
Download the current version from the source each time; forms change without notice.
Certificate of Medical Necessity for Home Health Services and Private Duty Nursing Services
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Only the qualifying treating physician may certify medical necessity. A collaborating advanced practice nurse or a physician assistant under the physician's supervision may conduct the face-to-face encounter, and their name and credentials are recorded on the form, but the certifying signature and date belong to the physician.
Within ninety days before the home health start of care date or within thirty days after it, per OAC 5160-12-01. The form records the name and credentials of the person who conducted the encounter and the encounter date, next to the certifying physician's signature and signature date.
For home health services, yes, if every data element listed in Section I is adequately contained in a prior authorized or approved plan of care. That note on the form refers to home health services; private duty nursing is certified separately in Section III.
No. The form states that under no circumstances does this certification determine a level of care for waiver eligibility or admission to a Medicaid-covered long-term care institution. Section II only asks you to certify that the patient's needs are comparable to an institutional level of care for home health purposes.