MassHealth Adult Foster Care Order Form
This file contains the MassHealth Adult Foster Care Order Form required for prior authorization. It includes sections for patient and provider information, clinical eligibility, and necessary attestations. Use this form when requesting AFC services for members.
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How do I fill this out?
To fill out this form, ensure all sections are completed accurately. Gather necessary information about the member and the AFC provider. Have the PCP review and sign the completed form.
How to fill out the MassHealth Adult Foster Care Order Form?
1
Gather member's personal and medical information.
2
Complete the AFC Provider and Member Information sections.
3
Assess and document the member's daily living activities.
4
Submit the form to the member's Primary Care Provider for approval.
5
Ensure all signatures and attestations are completed before submission.
Who needs the MassHealth Adult Foster Care Order Form?
1
Adult foster care providers who need to request approval for services.
2
Primary care providers verifying medical necessity for their patients.
3
Family members managing the care of individuals in adult foster care.
4
Case managers coordinating services for members within MassHealth.
5
Healthcare institutions requiring documentation for patient care.
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Make necessary edits, ensuring all information is correct.
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What are the instructions for submitting this form?
Submit this form by mailing it to the designated MassHealth office at the address provided on the form. Alternatively, you may also fax the completed documents to the number listed for your area. Be sure to keep copies of the documents for your records before submission.
What are the important dates for this form in 2024 and 2025?
Stay updated on any submission deadlines for this form in 2024 and 2025. Check with MassHealth for specific dates related to service requests and annual reviews, ensuring compliance with the latest guidelines.
What is the purpose of this form?
The purpose of the MassHealth Adult Foster Care Order Form is to establish a framework for requesting prior authorization for AFC services. This form ensures that both the AFC provider and the member’s primary care provider are aligned on the medical necessity of the services being requested. Proper completion of this form is crucial for obtaining the necessary approvals to deliver care.
Tell me about this form and its components and fields line-by-line.
- 1. Member Information: Includes the member's name, MassHealth ID, address, and date of birth.
- 2. AFC Provider Agency Information: Details about the AFC provider agency that are essential for authenticating the request.
- 3. Medical Necessity Assessment: Questions related to daily activities requiring assistance, and behavioral assessments.
- 4. Provider Attestation: Signature fields for both the AFC provider and PCP verifying the accuracy of the information.
- 5. Prescribing Provider Information: Details regarding the physician or nurse practitioner making the request.
What happens if I fail to submit this form?
Failure to submit this form accurately can lead to delays in receiving necessary services. It may result in denial of service requests and the member not receiving the care they need in a timely manner.
- Service Denial: Improper or incomplete forms may lead to rejection of the service request.
- Delayed Care: Without timely submission, there may be delays in care provision impacting member health.
- Legal Issues: Falsification of information could result in legal repercussions for providers.
How do I know when to use this form?
- 1. Initial Service Request: When first applying for AFC services for a member.
- 2. Periodic Review: For annual assessments to ensure continued eligibility for AFC.
- 3. Change in Care Needs: When there is a significant change in the member's health condition.
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What information do I need to fill out?
Collect the member's details, provider credentials, and medical necessity assessments.
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No account is needed, just ensure you have all required information ready.
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