Minimum data set (MDS) Form

Member Information
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Member's ID#*
Member's DOB*
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Date of RN Assessment*
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Name*
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Facility Information
Home Care Agency NPI*
Home Care Agency*
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Contact Name*
Contact Phone #*
Contact Fax #*
Email address in order to receive confirmation of request receipt*
RN signature*
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Enhanced Reimbursement
$1.00 per hour of combined personal car/home maker services. Services provided to a member assessed as being high acuity by the agency Registered nurse based on sections of the Minimum Data Set (MDS) for Home Care
Qualifications: A client is considered high acuity if they receive a following minimum score by an agency Registered Nurse in one area: a. “ on Section B items 1,2,3 OR b. “16” on Section E, Item 1, OR c. “8” on section E Items 2 and 3 OR d. “36” on Section H, items 1,2, and 3 Or, if they receive the following minimum scores in two or more areas a. “3” on Section B Items 1,2,3 b. “8” on Section E item 1 c. “4” on Section E items 2 and 3 d. “18” on Section H, Items 1,2, and 3 The agency must collect and submit this data to Neighborhood’s Utilization Department on all Integrity members in order to receive the enhancement for those with high acuity For all Integrity members that meet the minimum criteria described above, an authorization will be entered into the system upon receipt of the completed MDS form All MDS forms must be signed by an RN, dated, and totaled for each section Claims submitted for members meeting the acuity standard should be billed at the correct amount with the modifier “U9” Neighborhood’s UM staff will enter the necessary information from the MDS forms into the electronic member record system for those members meeting high acuity criteria. This will allow the enhanced payment to be paid only on the appropriate claims. Medical Management staff will review and monitor the MDS data and member assessments as necessary.

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Request Method*
Request Method *
- Standard
- Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
  Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.
Attach additional documents for Expedited request*
Accepted file types: pdf, doc, docx, Max. file size: 23 MB.
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Signature of Physician or Licensed Provider (Required for Expedited Request)
Signature Date
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Minimum data set (MDS) Form

Member Information

Facility Information

Section B: Cognitive Patterns

Section E: Mood and Behavior Patterns

Behavior Patterns

Section H: Physical Functioning - activities of daily living

Instrumental Activities of Daily Living

Enhanced Reimbursement