CurrentOptumPolicy N/A

Certification of Need for PRTF Services

Form and requirements to certify medical necessity for Psychiatric Residential Treatment Facility (PRTF) level of care for Nebraska Medicaid Managed Care enrollees; used by providers and evaluating teams when requesting initial authorization or re‑authorization. Applies to providers submitting requests to Nebraska Medicaid MCOs listed on the form.

Policy Summary

PayerOptum

PolicyCertification of Need for PRTF Services

Policy CodePolicy N/A

Change TypeMinor / No material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Certification of Need form (signed by physician, evaluating team members, and parent/guardian) to the listed Nebraska Medicaid MCO using the MCO-specific fax contacts.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PRTFlevel of care addressed

3signatures required

3MCOs listed

faxMCO contact method

Coverage and Medical Necessity Criteria

PRTF Admission Certification Criteria

Covered when ALL of the following are met (physician and evaluating team must attest):

PRTF Certification Elements: 1) Ambulatory care resources available in the community do not meet the treatment needs of the individual; 2) Proper treatment requires services on an inpatient basis under the direction of a physician; 3) The services can reasonably be expected to improve the individual's condition or prevent further regression so that the services will no longer be needed.all three statements must be checked/attested

Each element requires clinician attestation and signatures per form.

No explicit exclusions are listed on the Certification of Need form.

The form requires attestation by the physician and evaluating team to three specific certification elements. If these attestations are not completed, the lack of attestation indicates the individual does not meet medical necessity for PRTF level of care because the form requires confirmation that ambulatory resources are inadequate, that inpatient physician‑directed services are required, and that services are reasonably expected to improve the individual’s condition or prevent further regression.

Policy Summary

PayerOptum

PolicyCertification of Need for PRTF Services

Policy CodePolicy N/A

Change TypeMinor / No material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Certification of Need form (signed by physician, evaluating team members, and parent/guardian) to the listed Nebraska Medicaid MCO using the MCO-specific fax contacts.

SourceLink

On This Page

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What Providers Must Do

Prior Authorization

Authorization submission via MCO-specific form

A completed Certification of Need form specific to the member's Managed Care Organization (MCO) must be submitted to request initial authorization or re‑authorization for PRTF services. Use the MCO-specific fax/contact information when sending the form (e.g., UnitedHealthcare Community Plan fax 1-844-881-4926; Nebraska Total Care fax 1-866-593-1955; WellCare fax 1-877-849-5071).

Submit initial authorization or re-authorization using the Nebraska Medicaid Managed Care Program Certification of Need for Services form.
Select and send to the member's Managed Care Organization using the MCO-specific contact (fax) listed on the form.

Documentation Required

Required form completion and signatures

Complete all required form fields and obtain signatures before submission. Include admission date, authorization start/end dates, date of request, selected managed care organization, provider/facility contact details (name, phone, fax), ordering physician and NPI, facility name and Medicaid provider number, and full member information. Ensure the Physician and Evaluation Team Certification section is signed and dated by the physician, evaluating team members, and parent/legal guardian as applicable.

Required fields: Admission Date; Authorization Start Date; Authorization End Date; Date of Request.
Provider/facility fields: Provider/Facility Contact Person, Phone, Fax, Ordering Physician, NPI, Facility Name, Medicaid Provider #.
Member fields: Name, Date of Birth, Nebraska Medicaid #, Address, Contact phone and relationship.
Signatures required: Physician Signature with date; Evaluating Team Member(s) Signatures with dates; Parent/Legal Guardian Signature with date (as applicable).

Documentation Required

Consideration of less intensive care

Before certifying PRTF level of care, document that less intensive ambulatory community resources were considered and determined not to meet the individual's needs. Explicit documentation that outpatient, home, school, or community-based services were evaluated and found insufficient is required in the Certification of Need.

Document specific ambulatory resources considered (e.g., outpatient therapy, intensive outpatient, home-based services, school-based services) and reasons they are inadequate.
Include this documentation in the Certification of Need to support that inpatient PRTF is clinically necessary.

Definitions

PRTF — definition and certification elements

DefinitionPsychiatric Residential Treatment Facility (PRTF) level of care: inpatient psychiatric services provided under the direction of a physician for individuals whose psychiatric condition cannot be managed with ambulatory community resources.

Certification elements (must ALL be met)1) Ambulatory care resources available in the community do not meet the individual’s treatment needs; 2) Proper treatment requires inpatient services under the direction of a physician; 3) Services can reasonably be expected to improve the individual’s condition or prevent further regression so that the services will no longer be needed.

Required attestations/signaturesPhysician and evaluating team members must attest to each of the three certification statements; form includes signature lines for physician, multiple evaluating team members, and parent/legal guardian.

Purpose of certificationUsed to document medical necessity and to request initial authorization or re-authorization for PRTF services for Nebraska Medicaid managed care enrollees.

Regulatory referenceCertification language specifies PRTF level of care requirements are per CMS regulations.

OpenPayer

Certification of Need for PRTF Services

Coverage and Medical Necessity Criteria

PRTF / Inpatient Psychiatric Residential Criteria

What Providers Must Do

Definitions

Background