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Effective Date: 
3/2020

Documents

 

Instructions

Updated: 3/2020

 

Purpose

Form 2601 is used to record the physician’s certification of Medical Necessity for the applicant’s/member’s need for ongoing nursing services under the supervision of a physician. Nursing services can be provided in the home or a community-based setting program or in a nursing facility.

 

Procedure

When to Prepare

The managed care organization (MCO) service coordinator/service manager initiates the completion of this form for all initial assessments or with a significant change-in-status assessment. Form 2601 can be requested, but is not required, for annual reassessments when there are no significant change-in-status assessments.

Number of Copies

The original/electronic Form 2601 is maintained in the member's case record.

Form Retention

The MCO keeps Form 2601 according to the retention requirements found in all Medicaid managed care contracts and federal regulations. Keep all originals/electronic copies of this form in the member’s case record for five years after services are terminated.

Supply Source

This form is accessed at: https://hhs.texas.gov/laws-regulations/forms/2000-2999/form-2601-physician-certification.

 

Detailed Instructions

1. Applicant/Member Name — Enter the name of the applicant/member as entered on the Screening and Assessment Instrument (SAI).

2. Medicaid or Applicant Social Security Number — Enter the nine-digit Medicaid number as entered on the SAI. If the applicant does not have a Medicaid number, enter the Social Security number.

3. Date of Birth — Enter the member’s/applicant's date of birth.

4. Applicant/Member Primary Diagnosis — The physician enters the primary diagnosis of the applicant/member.

5. Other Active Diagnoses — The physician should enter the other active, pertinent diagnoses for which the applicant/member is receiving active treatment.

6. Certification – The physician should certify if they have examined the applicant/member in the last 12 months and reviewed all appropriate medical records, and if the physician certifies that the applicant/member requires ongoing nursing services under the direction of a physician.

6.a. The physician checks Yes if the physician certifies he/she has personally examined the applicant/member in the last 12 months and reviewed all appropriate medical records. The physician checks No if he/she has not personally examined the applicant/member and reviewed all appropriate medical records.

6.b. The physician checks Yes if he/she has personally examined the applicant/member in the last 12 months and reviewed all appropriate medical records, and the physician certifies the applicant/member requires ongoing nursing services under the direction of a physician. These services may be provided in a home or community-based setting or in a nursing facility.

The physician checks No if he/she has personally examined the applicant/member in the last 12 months and reviewed all appropriate medical records, but he/she does not believe the applicant/member requires ongoing nursing services provided in a home or community-based setting or in a nursing facility.

Signature of Physician and Date of Physician Signature — The physician must sign the certification and provide the date of the signature prior to the MCO submitting documentation to Texas Medicaid & Healthcare Partnership for a determination of medical necessity.

MD/DO Name — The physician or physician’s office staff enter the physician’s name.

MD/DO License Number — The physician or physician’s office staff enter the physician’s license number.

MD/DO License State — The physician or physician’s office staff enter the state which issued the license. If the physician is not licensed in the state of Texas, the state which issued the license must be Arkansas, Louisiana, New Mexico or Oklahoma for the certification to be valid.

Military Physician — Physicians employed or contracted with the Department of Defense can be licensed in any of the 50 states, the District of Columbia or United States territories. The physician or physician’s office staff enters Yes if the physician:

  • site of employment is in Texas; and
  • is not licensed in the state of Texas; and
  • works for the Department of Defense (DOD); or
  • is practicing in a health care facility of the DOD; or
  • is practicing in a civilian facility affiliated with the DOD; or
  • is practicing in any other location authorized by the Secretary of Defense.