Adult Nursing Services Prior Authorization Request (ANSPAR) Form
Adult Nursing Services Prior Authorization Request (ANSPAR) Form
Adult Nursing Services Prior Authorization Request (ANSPAR) Form
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<strong>Adult</strong> <strong>Nursing</strong> <strong>Services</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Request</strong> (<strong>ANSPAR</strong>) <strong>Form</strong>11Section: 1 Ongoing <strong>Adult</strong> <strong>Nursing</strong><strong>Request</strong>edHoursHealthcare 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:<strong>Request</strong>edUnitsRevised<strong>Request</strong>edHoursRevised<strong>Request</strong>edUnits____Hrs _____Units ____Hrs _____Units____Hrs _____Units ____Hrs _____Units____Hrs _____Units ____Hrs _____Units____Hrs _____Units ____Hrs _____Units12Section 2: Ongoing <strong>Adult</strong> <strong>Nursing</strong> - 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 Needs<strong>Request</strong>edHours<strong>Request</strong>edUnitsRevised<strong>Request</strong>edHoursRevised<strong>Request</strong>edUnits______Hrs _____Units ______Hrs _____Units______Hrs _____Units ______Hrs _____UnitsSection 2 Subtotal: ______Hrs _____Units ______Hrs _____Units13<strong>Request</strong> Totals<strong>Nursing</strong> Assessment & Consultation:Change of Condition:Ongoing <strong>Adult</strong> <strong>Nursing</strong> - Section 1:Ongoing <strong>Adult</strong> <strong>Nursing</strong> - 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)<strong>Adult</strong> <strong>Nursing</strong> <strong>Services</strong> to be delivered at LPN rate ______Hrs ____Units ______Hrs ____Units<strong>Adult</strong> <strong>Nursing</strong> <strong>Services</strong> to be delivered at RN rate ______Hrs _____Units ______Hrs _____UnitsTotal ______Hrs _____Units ______Hrs _____Units2 <strong>Adult</strong> <strong>Nursing</strong> <strong>Services</strong> <strong>Prior</strong> <strong>Authorization</strong> <strong>Request</strong> (<strong>ANSPAR</strong>) State of NM DOH/DDSDRevised 3/22/2013 DDSD/<strong>ANSPAR</strong>- 002
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