INSTRUCTION FOR FORM PCF03: REQUEST FOR REHAB EXTENSION. NOTE: Fields 1 5 MUST be filled in and you must attach a completed P.C. F01.
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1 INSTRUCTION FOR FORM PCF03: REQUEST FOR REHAB EXTENSION NOTE: Fields 5 MUST be filled in and you must attach a completed P.C. F0. Any incomplete form WILL BE REJECTED. Enter the assigned Pre-Certification Case Number.. Enter the 3-digit recipient Medicaid identification number. 3. Enter the recipient s last name, first name, and middle initial. 4. Enter the seven-digit hospital Medicaid number. 5. Enter the extension ICD-9-CM diagnosis code. An extension diagnosis code is required. Also, the description of the diagnosis is required. 6. If this is a reconsideration request, check this box. 7. Enter the appropriate outpatient surgical procedure codes, if applicable. 8. Enter the anticipated or actual date of surgery (if applicable). 9. Indicate the number of physician evaluations performed per 4 hours Use these fields to complete pertinent medical information regarding the recipient. If additional information is necessary, up to two pages may be submitted. 6. An authorized signature is required. Requests will not be accepted if not signed. 7. Enter the date this request is submitted to Molina.
2 Please Print or Type PAGE of PRE-CERT CASE # RECIPIENT ID NUMBER RECIPIENT LAST NAME FIRST MI PROVIDER NUMBER 3 4 ICD-9-CM EXTENSION DIAGNOSIS AND DESCRIPTION 5 CHECK HERE IF THIS REQUEST IS FOR A RECONSIDERATION 6 SURGICAL PROCEDURE ICD-9 (Hospital) 3 SUGGESTED GUIDELINES FOR MEDICAL DOCUMENTATION 7 8 SURGERY DATE / / 9 0 ) Physician evaluations times per 4 hours. ) Last multidisciplinary staffing date 3) Past medical history (Pertinent to extension diagnosis): 4) Physical exam findings (Pertinent to extension diagnosis): 5) Vital signs (List frequency. If febrile, list date and time. If cultures done, list date and result): 3 6) IV (List type and rate. Include ALL IV fluids and T.P.N.). Include type of access (peripheral, central): 4 7) Medications (List with dosage, route, and frequency, especially those relating to extension diagnosis): 5 8) Labs, X-Rays, and Procedures (List those pertinent to extension diagnosis): 6 9) Decubitus ulcers? Yes No If yes, list #, stage, and location. List applicable treatment(s) (dsqs, whirlpool, hyperbarics, etc.) 7 STATE OF LOUISIANA DHH BHSF P.C. F03 Issued 3/95
3 PAGE of PRE-CERT CASE # 0) Wounds other than decubitus ulcers? Yes No If Yes, list number, stage (if applicable), and location. List treatment(s) performed. 8 ) Pulmonary: Is patient on ventilator? Yes No Is patient weanable? Yes No If yes, tell how this is being accomplished. If no, explain why. 9 Respiratory treatments? Yes No If yes, list time and frequency. ) Nutritional Status: A) Mode of nutrition: TPN, NGT, GT/JT, or Oral. 0 B) Diet type: 3) Physical Therapy (Please summarize): 4) Occupational Therapy (Please summarize): 5) Speech Therapy (Please summarize): 3 6) Summary of medical necessity for hospitalization: 4 7) Discharge planning and/or estimated discharge date: 5 6 PROVIDER SIGNATURE: 7 DATE OF REQUEST: Up to two additional pages may be attached if necessary. P.C. F03 Issued 3/95
4 Please Print or Type PAGE of PRE-CERT CASE # RECIPIENT ID NUMBER RECIPIENT LAST NAME FIRST MI PROVIDER NUMBER ICD-9-CM EXTENSION DIAGNOSIS AND DESCRIPTION CHECK HERE IF THIS REQUEST IS FOR A RECONSIDERATION SURGICAL PROCEDURE ICD-9 (Hospital) SURGERY DATE / / 3 SUGGESTED GUIDELINES FOR MEDICAL DOCUMENTATION ) Physician evaluations times per 4 hours. ) Last multidisciplinary staffing date 3) Past medical history (Pertinent to extension diagnosis): 4) Physical exam findings (Pertinent to extension diagnosis): 5) Vital signs (List frequency. If febrile, list date and time. If cultures done, list date and result): 6) IV (List type and rate. Include ALL IV fluids and T.P.N.). Include type of access (peripheral, central): 7) Medications (List with dosage, route, and frequency, especially those relating to extension diagnosis): 8) Labs, X-Rays, and Procedures (List those pertinent to extension diagnosis): 9) Decubitus ulcers? Yes No If yes, list #, stage, and location. List applicable treatment(s) (dsqs, whirlpool, hyperbarics, etc.) P.C. F03 Issued 3/95
5 PAGE of PRE-CERT CASE # 0) Wounds other than decubitus ulcers? Yes No If Yes, list number, stage (if applicable), and location. List treatment(s) performed. ) Pulmonary: Is patient on ventilator? Yes No Is patient weanable? Yes No If yes, tell how this is being accomplished. If no, explain why. Respiratory treatments? Yes No If yes, list time and frequency. ) Nutritional Status: A) Mode of nutrition: TPN, NGT, GT/JT, or Oral. B) Diet type: 3) Physical Therapy (Please summarize): 4) Occupational Therapy (Please summarize): 5) Speech Therapy (Please summarize): 6) Summary of medical necessity for hospitalization: 7) Discharge planning and/or estimated discharge date: PROVIDER SIGNATURE: DATE : Up to two additional pages may be attached if necessary. P.C. F03 Issued 3/95
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