Pursuant to federal guidelines for - Vantage Health Plan 2026

1. Click ‘Get Form’ to open the Home Health Pre-Certification Worksheet in the editor.
2. Begin by selecting the type of request. Check the appropriate box for either 'Initial 30-day Request' or 'Additional 30-day Request(s)'. Fill in the 'Dates of Service Requested' and 'PDGM/HIPPS' fields.
3. In the Patient Information section, enter the patient's name, member ID, address, date of birth, and phone number.
4. Provide Admission/Agency Information by filling in details such as agency name, contact name, phone number, address, NPI number, and fax number.
5. Complete the Physician Information section with the physician's name, phone number, address, NPI number, and fax number.
6. Indicate the Admission Source and Timing by checking the relevant boxes for institutional or community sources and specifying timing.
7. Fill out Medical Information including primary diagnosis with ICD-10 code and any secondary diagnoses if applicable.
8. Attach clinical documentation as required. Check all applicable boxes for documents attached for review.
9. Complete sections on Current Homebound/Functional Status and Caregiver Availability. Provide details about caregiver availability if applicable.
10. Finally, summarize clinical information including care plans and barriers to care. Ensure all sections are completed before submitting your form.

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