Spreadsheet: 154ad714-e8d0-45ee-8ad5-2e9cd7f7cc65
Sheet: Sheet1

Unnamed: 0 | STATE OF COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11 | Unnamed: 12 | Unnamed: 13 | Unnamed: 14 | Unnamed: 15 | Unnamed: 16
 |  |  |  | Medical Assistance Program Prior Authorization
 |  |  |  | [NAME] Health |  |  |  |  |  |  |  | PA Number being revised:
 |  |  |  |  |  |  |  |  |  |  |  | Revision?
 | 1. CLIENT NAME |  |  |  | 2. CLIENT ID |  |  |  | 3. BIRTHDATE |  |  | 4. HCBS ELIGIBLE
 | 5. REQUESTING PROVIDER # |  |  | 6. REQUESTING AGENCY |  | 7. CASE MANAGEMENT AGENCY # |  |  | 8. DATES COVERED
 |  |  |  |  |  |  |  |  | From: |  |  | Through:
 | STATEMENT OF REQUESTED SERVICES
 | 9. Revenue Code/ Description |  |  |  |  | 10. Specify Frequency | 11.  # [NAME] | 12. Cost Per Unit | 13. Total $ [NAME] |  | 14. Total Units Authorized | 15. PAR Determination | 16. Comments |  | 9 | 12
 | 551 RN/LPN |  |  |  |  |  |  | 101.09 | 0
 | 590 Uncomplicated Nursing Visit, 1 |  |  |  |  |  |  | 70.76 | 0 |  |  |  |  |  | 551 RN/LPN | 101.09
 | 599 Uncomplicated Nursing Visit, 2+ |  |  |  |  |  |  | 49.53 | 0 |  |  |  |  |  | 590 Uncomplicated Nursing Visit, 1 | 70.76
 | 571 Certified Nurisng Assistant (CNA), Basic |  |  |  |  |  |  | 35.95 | 0 |  |  |  |  |  | 599 Uncomplicated Nursing Visit, 2+ | 49.53
 | 579 Certfied Nursing Assistant (CNA), Extented |  |  |  |  |  |  | 10.75 | 0 |  |  |  |  |  | 571 Certified Nurisng Assistant (CNA), Basic | 35.95
 | A |  |  |  |  |  |  |  |  |  |  |  |  |  | 579 Certfied Nursing Assistant (CNA), Extented | 10.75
 | B
 | C
 | D |  |  |  |  |  |  |  |  |  |  |  |  |  | 16
 | E
 | F |  |  |  |  |  |  |  |  |  |  |  |  |  | A
 | G |  |  |  |  |  |  |  |  |  |  |  |  |  | D
 | H |  |  |  |  |  |  |  |  |  |  |  |  |  | PA
 | 17. TOTAL REQUESTED ADULT LONG TERM HOME HEALTH EXPENDITURES (SUM OF AMOUNTS IN COLUMN 13 ABOVE) |  |  |  |  |  |  |  |  |  |  |  | 0
 | 18. NUMBER OF DAYS COVERED (FROM FIELD 8 ABOVE)
 | 19. ADDITIONAL INFORMATION:
 | CASE MANAGER USE
 | 20.  CASE MANAGER [NAME] |  |  |  | 21.  AGENCY |  |  | 22. PHONE # |  | 23. EMAIL |  |  | 24.  DATE
 | 20A. CASE MANAGER SIGNATURE:
 | DO NOT WRITE BELOW - AUTHORIZING AGENT USE ONLY
 | 25. HOME HEALTH PAR: |  |  |  |  |  |  |  |  |  |  | Return for correction- Date:
 | 26. DENIAL REASON:
 | 27. DEPARTMENT APPROVAL SIGNATURE: |  |  |  |  |  |  |  |  |  | 28.  DATE:
 | PAR Completion Instructions
 | FORM MUST BE COMPLETED ELECTRONICALLY- PLEASE PRINT
 | Complete this form for Prior Authorization Requests for Adult Long Term Home Health.  Submit the PAR per the instructions listed at the bottom. Please include the Plan of Care and other supporting documentation.
 | For PAR Revisions:
 | Complete the Revision section at the top of the form only if revising a current approved PAR. The number of units should equal more/less the number of units planned for use during the PAR period. The number of units being requested needs to be added to the original number of units approved and include all services that were approved on the original PAR. Use one of the eight (8) lettered (A-H) dropdown fields found in the first few lines immediately following the last code in Column 9, the “Description” column when a Revision requires: 1) Additional lines of existing codes to indicate varying rates, units, etc.;  2) The inclusion of codes for a timeframe that used codes not listed on the existing form; 3) Change of Provider.
 | Complete the following required fields:
 | 1 |  | Client Name:  Enter the client's name.
 | 2 |  | Client ID:  Enter the client's Medical Assistance Program ID number.
 | 3 |  | Birthdate:  Enter the client's date of birth.
 | 4 |  | HCBS Eligible: Check “yes,” if client is currently enrolled in a waiver program.  Check “no,” if client is not currently enrolled in a waiver program or is on the wait-list for a waiver program (HCPF or DD).
 | 5 |  | Requesting Provider #: Enter the requesting provider's Medical Assistance Program provider number.
 | 6 |  | Requesting Agency: Enter requesting home health agency.
 | 7 |  | Case Management Agency #: Enter the Case Management Agency number.
 | 8 |  | [NAME] (From and Through):  Enter the PAR start date and PAR end date.
 | 9 |  | Description:  List of approved procedure codes.
 | 10 |  | Specify Frequency: Enter visit frequency for home health service requested using daily/weekly,etc.
 | 11 |  | # [NAME]:  Enter the number of units next to the services for which reimbursement is being requested.
 | 12 |  | Cost Per Unit: Cost per unit automatically populates.
 | 13 |  | Total $ [NAME]:  The total dollar amount requested for the service automatically populates.
 | 14 | 14 | Total Units Authorized: The Authorizing entity enters the total number of a units approved per the line.
 | 15 |  | PAR Determination: This box is completed by the designated review agency. Select the appropriate determination. Approved (A), Partially Approved (PA), Denied (D)
 | 16 | 14 | Comments - Optional:  Enter any additional useful information. For PAR revisions this is a required field and should include if a service is authorized for different dates than in Box 8, please include the procedure code and date span here.
 | 17 |  | Total Requested Expenditures:  Total automatically populates.
 | 18 | 14 | Number of Days Covered:  The number of days covered automatically populates.
 | 19 |  | Additional Information - Optional: Home Health Agencies may use this field to explain the reasons for requested frequency, duration, medical necessity, or by CMA to explain reasons for denial or approval of a reduced amount, as needed.
 | 20 | 14 | Case Manager Name:  Enter the name of the Case Manager.
 | 20A. |  | Case Manager Signature:  Case Manager signature.
 | 21 |  | Agency:  Enter the name of the agency.
 | 22 |  | Phone #: Enter the phone number of the Case Manager.
 | 23 |  | [NAME]: Enter the email address of the Case Manager.
 | 24 |  | Date:  Enter the date completed.
 | “DO NOT WRITE BELOW - AUTHORIZING AGENT USE ONLY”. This is for Department use only.
 | Send only New and Revised PARs to:
 | Adult with DHS Waivers (DD, DHSS, SLS)  --> CCB
 | Adult with or without [NAME] (BI, CMHS, EBD, PLWA, SCI) --> CMA/SEP
 | Note: If submitted to the Department’s Fiscal Agent, the following correspondence will not be returned to case managers, outreach will not be performed to fulfill the requests, and all such requests will be recycled: 1) Paper PAR forms that do not clearly identify the case management agency or have incorrect client information in the event the form(s) need to be returned and/or 2) PAR revision requests not submitted on Department approved PAR forms, including typed letters with revision instructions. Should questions arise about what Fiscal Agent staff can process, please contact the Home Health Policy Specialist.