Assisted Living - NHPRI.org

Member Information
Enter Member Id and Date of Birth to validate Member before proceeding with the form.
Member's ID#*

11 digits
Member's DOB*
MM slash DD slash YYYY
Start Date being requested*
MM slash DD slash YYYY
Member's Name*
First Last
Error Message
Facility Information
Assisted Living facility NPI*

10 digits
Assisted Living Facility Name*
Error Message
Phone #*
Fax #*
Contact Name*
Email address in order to receive confirmation of request receipt*

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Clinical Information
Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*
Diagnosis ICD 10 Diagnosis Code

Example ICD 10 Diag Code: Z87.890
CPT/HCPC Code (Click + or - at the right to add up to 5 codes)*
Code Type Code

5 numbers OR 1 letter and 4 numbers
Example CPT code: 12345
Example HCPC code: T2031
Please note: For a full description of each Tier please refer to Assisted Living Services Description and Certification Standards found at www.nhpri.org*
Check the box that applies to level of care you are requesting.
Please note: For a full description of each Tier please refer to Assisted Living Services Description and Certification Standards found at www.nhpri.org *
- Tier A Services: Daily assistance with at least two (2) activities of daily living (ADLs) Includes personal care, homemaker, chore, attendant care, companion services, medication administration and/or oversight (to the extent permitted under State law), therapeutic social and recreational programming, and 24-hour on-site response staff to meet scheduled or unpredicted needs. Services must be provided in a home-like environment.
- Tier B Services: Includes all services included in Tier A plus any or a combination of additional services. Extensive assistance with at least two (2) ADLs, or 7 hours or more of any combination of personal care, limited health care services and care coordination (including behavioral health) and/or health and home stabilization service. Extended personal care including complex medication management and attendant services, care coordination and therapeutic activities and/or limited health services.
- Tier C Services: Includes all services included in Tier A & B plus any or a combination of additional service. Extensive assistance with at least three (3) ADLs and Sixteen (16) hours or more of ADL care including any combination of personal care, limited skilled nursing, and/or behavioral health or health and home stabilization services. Providing support and education to the resident about managing specific health conditions as documented in the resident’s person-centered service plan. Regular staff intervention due to safety concerns related to elopement risk or other behaviors that adversely impact themselves or others.
Signature of Treating Physician or Licensed Provider*
Signature Date

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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 Clinical documents for Expedited request*
Accepted file types: pdf, doc, docx, Max. file size: 23 MB.
Upload only PDF or Word Document
Signature of Physician or Licensed Provider (Required for Expedited request)*
Signature Date
Comments
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Diagnosis	ICD 10 Diagnosis Code

Code Type	Code

Member Information

Facility Information

Clinical Information