Adult Nursing Services Prior Authorization Request (ANSPAR) Form

Adult Nursing Services Prior Authorization Request (ANSPAR) Form1Date Sent to CM:2Date CM Received: 3Sign:4 Client Name:5 Client’s full ISP Cycle Dates:SS:Current Address:City:6 Submitter/Contact Person:DOB:Zip Code:From:To:Revision Dates, if different from ISP Cycle:From:To:7 Current Case Manager:Agency:Phone:Fax:Email:8 Current Services (Nursing & BSC Only: check all that apply): Supported Living Intensive Medical LivingAgency:Phone:Email:Fax:9 Current NMDDW Group Category:A B C D E F G H Family Living-Bio Customized In HomeSupports Family Living-Host Crisis Supports PRSCCommunity Integrated EmploymentCustomized Community Supports10Nursing Assessment & ConsultationFor Information Purposes ONLY• 12 hours may be budgeted without PA for initial/annual• 8 hours may be added without PA with significant changeof conditionHoursBudgetedUnitsBudgetedRevised HrsRevisedUnitsNursing Assessment & Consultation ____Hrs ____Units ____Hrs ____UnitsSignificant Change of Condition ____Hrs ____UnitsTotal ____Hrs ____Units ____Hrs ____Units1 Adult Nursing Services Prior Authorization Request (ANSPAR) State of NM DOH/DDSDRevised 3/22/2013 DDSD/ANSPAR- 002

Adult Nursing Services Prior Authorization Request (ANSPAR) Form11Section: 1 Ongoing Adult NursingRequestedHoursHealthcare Planning & Coordination• Up to 20 additional hours annuallyAspiration Risk Management• Newly identified / 20 hrs annually• Existing CARMPs / 12 hrs annuallyDelegation• Up to 36 hours annuallyMedication Oversight• Up to 20 hrs annuallySection 1 Sub Total:RequestedUnitsRevisedRequestedHoursRevisedRequestedUnits____Hrs _____Units ____Hrs _____Units____Hrs _____Units ____Hrs _____Units____Hrs _____Units ____Hrs _____Units____Hrs _____Units ____Hrs _____Units12Section 2: Ongoing Adult Nursing - ComplexWhen requesting hours for Medication delivery by a DD Waiver Nurse or Coordination of ComplexConditions, additional justification must be submitted.Medication Administration by DDW Licensed Nurse• Up to 160 hrs additional with Very High NeedsCoordination of Complex Conditions• Up to 196 hrs additional with Very High NeedsRequestedHoursRequestedUnitsRevisedRequestedHoursRevisedRequestedUnits______Hrs _____Units ______Hrs _____Units______Hrs _____Units ______Hrs _____UnitsSection 2 Subtotal: ______Hrs _____Units ______Hrs _____Units13Request TotalsNursing Assessment & Consultation:Change of Condition:Ongoing Adult Nursing - Section 1:Ongoing Adult Nursing - Section 2:______HrsNA______Hrs______Hrs____UnitsNA____Units____Units______Hrs______Hrs______Hrs______Hrs____Units____Units____Units____Units14Total:______Hrs____Units______Hrs____UnitsApportionment of Units Between LPN and RN billing codes (total must match total above)Adult Nursing Services to be delivered at LPN rate ______Hrs ____Units ______Hrs ____UnitsAdult Nursing Services to be delivered at RN rate ______Hrs _____Units ______Hrs _____UnitsTotal ______Hrs _____Units ______Hrs _____Units2 Adult Nursing Services Prior Authorization Request (ANSPAR) State of NM DOH/DDSDRevised 3/22/2013 DDSD/ANSPAR- 002

Adult Nursing Services Prior Authorization Request (ANSPAR) Form15The following supporting documentation is included with this Adult Nursing Services P.A. Request:Required Attachments e-CHAT including MAAT,ARST & e-CHAT SummaryReportRequired Attachments for Complex Justification report forMedication Administration byDDW Licensed Nurse Justification report forCoordination of ComplexConditionsOther Pertinent Documents considered necessaryby Requesting Nurse MARS Quarterly/Semi Annual Nursing Reports fromTherap Orders HCPs/CARMP MERPs Specialist Reports Diagnostic Reports History & Physical Progress Notes Data Other Critical Medical Information or History16 TPA UTILIZATION REVIEW SECTION ONLY1. Ongoing Adult Nursing Services Approved Units Denied Units1a. Healthcare Planning & Coordination1b. Aspiration Risk Management1c. Delegation1d. Medication Oversight2. Ongoing Adult Nursing Complex2a. Medication Administration by Licensed Nurse2b. Healthcare Coordination of Complex ConditionsTPA/UR Reviewer First and Last Initial: Date Reviewed: Prior Authorization #:3 Adult Nursing Services Prior Authorization Request (ANSPAR) State of NM DOH/DDSDRevised 3/22/2013 DDSD/ANSPAR- 002