Directions for completing an EPSDT Extraordinary Home Health PAR

Please be aware that the same form is used for Prior Authorization Requests for EPSDT Extraordinary Home Health, Private Duty Nursing, and Long Term Home Health.

Be sure that you send only PARs for EPSDT Extraordinary Home Health Services to CFMC.

Please submit Long Term Home Health and Private Duty Nursing PARs to the following agencies:

Long Term Home Health PARS for clients age 18 and over should be sent to
the Single Entry Point (SEP) agency in the client’s county of residence.

Long Term Home Health PARs for clients under 18 years of age should be sent to the fiscal agent (ACS) at:

ACS
PO Box 30
Denver, CO 80201-0030

PARs for the Private Duty Nursing program should be sent to:

Dual Diagnosis Management (DDM)
220 Venture Circle
Nashville, TN 37228
Fax: 877-431-9568

Submit EPSDT HH PARS to:

Colorado Foundation for Medical Care
23 Inverness Way East, Suite 100
Englewood, CO 80112-4708
Fax: 303.695.3377

Private Duty Nursing (PDN) and Long Term Home Health (LTHH) PARS should NOT be submitted to CFMC.

Submit appropriate documentation to support your request including detailed demographics, diagnoses, physician’s orders, treatment plans, medications, etc.

Acceptable documentation includes a completed CMS-485 form, physician orders, and admission paperwork for EPSDT HH.

Complete the Revision section at the top of the form only if you are revising a current approved PAR.

Complete the following fields:

• Client Name - Required
• Client Medical Assistance Program ID number – Required [This is a letter followed by six digits.]
• County Number - Required
• Date - Required
• PAR start date - Required
• PAR end date - Required

Circle the type of program (EPSDT) for which you are requesting services.

Enter the number of units next to the services for which you are requesting reimbursement.

Do not enter anything to the right of the double vertical line. This is for the authorizing agency use only.

Complete the following:

• Enter your agency name - Required
• Sign your name - Required
• Enter the Medical Assistance Program Provider ID number - Required [This is an eight digit number.]
• Narrative information - Home Health Agencies may use this field to explain the reasons for requested frequency, duration, medical necessity, or by CFMC to explain reasons for denial or approval of a reduced amount, as needed.

Do not write in the following sections:

• Denial Reason Codes - Authorizing agent use only.
• Signature of Authorizing Party - Authorizing agent use only.
• Date PAR processed - Authorizing agent use only.