| May use same information as on NYMC Pre-implementation List - REQUIRED |
Column B- CIN (required) |
The child/youth's Medicaid client identification number (CIN) |
| Column C- DOB (required) |
The child/youth's date of birth (DOB) in month/date/four digit year format |
| Column D- First (required) |
The child/youth's first name |
| Column E-Last (required) |
The child/youth's last name |
| Column F- DFR County (required) |
The child/youth's district of fiscal responsibility(DFR)- choose from drop down list |
| To be completed by 29-I Health Facility - REQUIRED |
Column G- Placement County (required, as applicable) |
The child/youth's placement county, if different from the district of fiscal responsibility (DFR) County -choose from drop down list |
| Column H- Placement Type (required) |
The child/youth's placement type - choose from drop down list |
| Column I- Eligible for Core LHRS (required) |
Enter Y if the child/youth is eligible for Core Limited Health Related Services (CLHRS) residual per diem. Enter N if the child/youth is not eligible for CLHRS. |
| Column J-Eligible for Other LHRS (required) |
Enter Y if the child/youth is eligible for Other Limited Health Related Services (OLHRS) residual per diem. Enter N if the child/youth is not eligible for OLHRS. |
| Column K- MMC Plan Name (required) |
The name of the child/youth's Medicaid managed care plan on July 1, 2021 |
| |
Primary Care Provider (PCP) and Health Home (HH) |
| Column |
Information to be entered |
| To be completed by 29-I Health Facility - REQUIRED |
Column L- PCP and Practice Name (required if known) |
The first and last name of the child/youth's primary care provider (PCP) and the primary care provider's practice name (if applicable). If PCP not provided, or is not subsequently chosen and communicated to the MMC Plan, the MMC Plan is required to assign a PCP |
| Column M- PCP NPI (required, if known) |
The national provider identifier (NPI) of the child/youth's primary care provider |
| Column N- PCP Phone Number (required, if known) |
The phone number of the child/youth's primary care provider, including area code |
| Column O- PCP Address (required, if known) |
The address of the child/youth's primary care provider, including city, state, and zip code |
| To be completed by 29-I Health Facility - Optional |
Column P- Health Home (optional) |
The name of the child/youth's health home |
| Column Q- Health Home Care Manager (optional) |
The first and last name of the child/youth's health home care manager |
| Column R-Health Home Care Manager Phone Number (optional) |
The phone number of the child/youth's health home care manager, included area code |
| |
Care Needs for 7/1/21 and Ongoing Requiring Notice or Authorization |
| Column |
Information to be entered |
To be completed by 29-I Health Facility - Optional
NOTE: providing as much information as known and available will enable the MMC Plan to set up services on their systems and assist follow-up work though liaisons |
Column S- Service Needed- Category (optional) |
The general service category requiring notice or authorization - choose from drop down list Note : a new row should be completed for each service that a child/youth needs that requires notice or authorization |
| Column T- Requesting Provider Name (optional) |
The first and last name of the provider requesting the service in Column S Note: this may be the 29-I Health Facility/LDSS/Court or a community provider |
| Column U- Diagnosis or Working Diagnosis (optional) |
The diagnosis, or working diagnosis, that necessitates the service identified in Column S |
| Column V-Procedure/ Service Name (optional) |
The name of the specific procedure or service requiring notice or authorization |
| Column W- Procedure Code (optional) |
The billing code that corresponds with the procedure/service identified in Column V |
| Column X-Service Units (optional) |
The amount of units needed of the service that is identified in Column V. |
| Column Y- Services Frequency/Scope/Duration (optional) |
As applicable, the frequency of services needed, hours needed per service, and length of time the service identified in Column V will be needed Example: 2 hours per week for 6 weeks |
| Column Z-Servicing Provider Name (optional) |
The first and last name of the provider who is providing, can provide, or will provide the service listed in Column V |
| Column AA- Servicing Provider Phone Number (optional) |
The phone number of the provider in Column Z, including area code |
| Column AB- Servicing Provider Address (optional) |
The address of the provider in Column Z, including city, state, and zip code |
| Column AC- Servicing Provider NPI (optional) |
The national provider identifier (NPI) of the provider in Column Z |
| Column AD- Servicing Provider TIN (optional) |
The tax identification number (TIN) of the provider in Column Z |
| Column AE- Service Notes (optional) |
Any additional information pertaining to child/youth; the service category in Column S; or the procedure/service listed in Column V. Add note if additional documentation is being shared/attached. See template for examples |
