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*
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
Check the box that applies to level of care you are requesting.
Check the box that applies to level of care you are requesting.
- Base-Level: 6 hours or more of personal care per week 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.
- Enhanced-Level: Non skilled Provides the base level service package and offers extended personal care and attendant services, care coordination and therapeutic activities and/or limited health services. The enhanced service package may also include coordination of behavioral health services, or health and home stabilization services that optimize a beneficiary's general health and welfare
- Enhanced-Level: Skilled Care Provides the base level service package and offers extended personal care and attendant services, care coordination and therapeutic activities and/or limited health services. The enhanced service package may also include coordination of behavioral health services, or health and home stabilization services that optimize a beneficiary's general health and welfare. And also requires at least one skilled service by a Registered Professional nurse (RN) or a Licensed Practical Nurse (LPN)
- Dementia Care: Member must have a diagnosis of Alzheimer's disease or another related dementia and be determined to need memory care. Beneficiaries must need assistance with at least three (3) of the activities of daily living and require thirteen (13) hours or more of any combination of personal care, limited skilled nursing, and/or behavioral health or health and home stabilization services.
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
Authorization is not a guarantee of payment
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Diagnosis	ICD 10 Diagnosis Code

Code Type	Code

Step 1 of 4

Member Information

Facility Information

Clinical Information