Physician Certification Form in PA: A Guide

Physician Certification

Physician Certification Form in PA: A Guide

Looking for the Physician Certification Form in Pennsylvania as part of the Medicaid waiver and getting home and community based services such as home care? We provide that for you here and also give a complete guide in understanding it. 

Just want a copy of the physician certification form? Click here to print or download it now. 

The eligibility for home and community-based services (HCBS), either through a Medicaid waiver or a state-funded program, requires an individual to meet certain criteria specific to each waiver or program. Home and community-based services are a variety of services that an individual can receive to help keep them living and residing in the community or in their own home. The most common example of services that these individuals receive is home care services. An individual must meet financial criteria to qualify as well as clinical criteria. As part of the clinical criteria, a physician certification form must be completed and submitted.


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Qualifying based on clinical criteria

As part of the clinical, or medical, criteria, an individual will need an assessment completed as well as a physician certification. These are done to ensure that the person applying for services has a certain level of care need in which services would help them.

The physician certification form is a state form that must accompany the application for Medicaid waiver services. It is also known as the MA 570 form. It is sent to an applicant’s physician or provider and then they review the information and verify that the applicant meets the clinical criteria portion to receive services. 

When is the physician certification form completed?

The physician certification form is completed initially when a participant attempts to sign up with home and community based services (HCBS) as well as the LIFE program. The individual applying for the program must be deemed and certified Nursing Facility Clinically Eligible (NFCE) by the physician. If they are not found to be NFCE then they are considered to be Nursing Facility Ineligible (NFI).

It is done when an individual initially applies to qualify for these services. The physician certification form must also be filled out and submitted to the state of Pennsylvania on a yearly basis as well. This is done to make sure that the individual is still considered NFCE and has not become ineligible (NFI). 


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Who must sign the physician certification form in Pennsylvania?

The form must be signed by a doctor, such as an MD (Medical Doctor) or DO (Doctor of Osteopathic Medicine). It cannot be signed by anyone else, such as a Physician’s Assistant, Nurse Practitioner, or other physician extenders.

Does it have to be signed by the primary care physician?

No, it does not have to be signed by the primary care physician. It can be signed by the primary care physician or another physician specialist. The important thing is that it is signed by a physician or doctor. 

How long does the physician have to sign and return the form?

The form recommends that the physician returns the form within 5 days. To prevent delays, the participant is recommended to follow up with their physician or doctor’s office to ensure a timely return of the form. 

Who manages the physician certification form in PA?

The process is managed by the PA IEB (Pennsylvania Independent Enrollment Broker). The form is sent from the PA IEB. When the physician completes the certification form, it is also returned to the PA IEB as well. 


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How can the physician certification form be sent?

It can be sent to the PA IEB via fax or mail. The fax number for the PA Independent Enrollment Broker (PA IEB) is 888-349-0264. 

If mailing the form, it can be sent to the PA IEB at P.O. Box 61560, Harrisburg, PA 17106. 

Is the physician certification form required?

Yes, the application cannot move forward until the physician certification form is completed and returned to the PA IEB.

What are the level of care (LCD) definitions that the physician must certify for the applicant?

The following definitions come straight from the level of care determination that is evaluated. Keep in mind that the individual must be determined to be NFCE in order to meet clinical qualification to continue to be eligible. 

Nursing Facility Clinically Eligible (NFCE) 

The individual has an illness, injury, disability or medical condition diagnosed by a physician; and as a result of that diagnosed illness, injury, disability or medical condition, the individual requires care and services above the level of room and board; and a physician certifies that the

individual is NFCE; and the care and services are either a) skilled nursing or rehabilitation services as specified by the Medicare Program in 42 CFR §§ 409.31(a), 409.31(b)(1) and (3), and 409.32 through 409.35; or b) health-related care and services that may not be as inherently complex as skilled nursing or rehabilitation services but which are needed and provided on a regular basis in the context of a planned program of health care and management and were previously available only through institutional facilities.

Nursing Facility Ineligible (NFI)

Individuals who do not meet the definition of Nursing Facility Clinically Eligible are considered NFI. 

Intermediate Care Facility for Persons with Other Related Conditions (ICF/ORC)

Has a diagnosis of Other Related Condition (ORC), a severe, chronic disability –other than a mental illness or an intellectual disability – that manifested before age 22, is likely to continue indefinitely, results in an impairment of either general intellectual functioning or adaptive behavior, and results in substantial functional limitations in at least three of these areas: self-care, understanding and use of language, learning, mobility, self-direction, and capacity of independent living, and Requires active treatment – a continuous program that aggressively, consistently gives specialized and generic training, treatment, health services and related services; that focuses on the client acquiring behaviors necessary to function with as much self-determination and independence as possible ; and that aims to prevent or slow regression or loss of current optimal functional status.


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What does the form look like?

You can find the form in its entirety to be used or printed right here. To see what the form asks, you can reference the below section. Please note that this section below should not be used and only the form as listed here should be used.


Information from the PA physician certification form, MA 570

This form is intended for the sole use of the individual or entity to whom it is addressed and contains protected health information (PHI) subject to provision under the law, including the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA). Providers may not submit false information to obtain authorization to furnish services or items under Medical Assistance.

DIAGNOSIS

Please list all diagnoses with ICD codes related to patient’s need for care. Please ensure that you include diagnoses of brain injury and/ or developmental disability if present.

 

ICD 10 CODE: PHYSICIAN DIAGNOSIS:

 

LEVEL OF CARE

For individuals 60 years of age or older, please only select between NFCE or NFI.

Nursing Facility Clinically Eligible (NFCE) – This individual has an illness, injury, disability or medical condition diagnosed by a physician; and as a result of the illness, injury, disability or medical condition, the individual requires the level of care and services

provided in a nursing facility above the level of room and board.

Nursing Facility Ineligible (NFI) – This individual does not meet the definition of NFCE.

Intermediate Care Facility for Persons with Other Related Conditions (ICF/ORC) – This individual requires services at the level of an ICF/ORC, because the individual requires active treatment and has a diagnosis of an ORC.

ORC – A severe chronic disability (other than mental illness or an intellectual disability) that: (1) manifested before age 22;

(2) is likely to continue indefinitely; (3) results in the impairment of either general intellectual functioning or adaptive behavior; and

(4) results in substantial functional limitations in at least three of the following areas of major life activities: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living. ORCs may include, but are not limited to: cerebral palsy, spina bifida, epilepsy, severe physical disabilities, and autism.

Active Treatment – A continuous program which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services that is directed toward the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible and the prevention or deceleration of regression or loss of current optimal functional status. Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.

 

LENGTH OF CARE REQUIRED

Please indicate length of care required related to the diagnosis listed.

Long Term – Condition or disability is anticipated to last 12 months or longer.

Short Term – Condition or disability is anticipated to last less than 12 months.

PHYSICIAN INFORMATION

 

PHYSICIAN NAME (MUST BE MD OR DO): PHYSICIAN LICENSE # OR MA ID #:

PHYSICIAN PHONE: PHYSICIAN FAX:

PHYSICIAN SIGNATURE: DATE:

 

PATIENT NAME:

 

 THIS SECTION MUST BE COMPLETED IF YOUR PATIENT’S IDENTIFIED LEVEL OF CARE IS ICF/ORC

 

INSTRUCTIONS: Please check Yes or No to indicate whether or not the patient has a substantial limitation in any of the six areas below. In addition, for those areas checked “Yes,” please provide comments to substantiate your response.

 

Self-Care: A long-term condition which requires the patient to need significant assistance with personal needs such as eating, hygiene, and appearance. Significant assistance may be defined as assistance with at least one-half of all activities normally required for selfcare.

 

Yes No Comments:  

 

Receptive and Expressive Language: A patient is unable to effectively communicate with another person without the aid of a third person, a person with special skills or with a mechanical device, or a condition which prevents articulation of thoughts.

 

Yes No Comments:  

 

Learning: A patient that has a condition which seriously interferes with cognition, visual, or aural communication, or use of hands to the extent that special intervention or special programs are required to aid in learning.

 

Yes No Comments:  

 

Mobility: A patient that is impaired in his/her use of fine motor skills to the extent that assistance of another person and/or a mechanical device is needed in order for the patient to move from place to place.

 

Yes No Comments:  

 

Self-Direction: A patient that requires assistance in being able to make independent decisions concerning social and patient activities and/or in handling personal finances and/or in protecting his/her own self-interest.

 

Yes No Comments:  

 

Capacity for Independent Living: A patient that is limited in performing normal societal roles or it is unsafe for the patient to live alone to such an extent that assistance, supervision, or presence of a second person is required more than one-half the time (during waking hours).

 

Yes No Comments:  

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