What we need from you to start a referral

Start before you have everything

A referral is opened on a name, a date of birth and a reachable phone number. Everything below is worked after intake, not before it. Holding a referral while an office locates a form costs clock that cannot be recovered later, and most of these documents can be obtained during the process anyway. The one item that genuinely stops work is marked below as a hard stop.

Member identifiers and Medicaid status

The clinical picture

Function, not diagnosis alone. A diagnosis list without an account of what the person can no longer do for themselves does not support a level-of-care determination.

• Current functional deficits – bathing, dressing, transfers, toileting, continence, eating, medication management, mobility inside and outside the home, and night-time supervision needs. This is the substance of the DON-R. Without it, the assessment starts from zero.
• Cognitive status, including documented dementia, wandering or unsafe behaviors.
• Diagnoses and current medication list. The medication list drives whether the case is a Traditional or an Enhanced case management fit.
• Recent acute history – falls, hospitalizations, ED visits.
• The home environment – who else lives there, stairs, bathroom access, whether the person is alone overnight.

If you hold a completed assessment of any kind, send it rather than summarizing it.

Level-of-care documentation

• DMA-6 – the medical form used in the level-of-care determination. Send a current one if you have it. If not, it is obtained during the process.
• Any completed DON-R or equivalent functional scoring from a prior assessment.
• Physician name and practice contact. Useful, but note that under General Services §602.11 the plan of care and the level-of-care attestation may be signed by the member’s own physician or by the case management agency’s medical director. An agency with a medical director on staff does not have to wait on the member’s physician for that signature.

Missing level-of-care documentation is the most common gap and the least damaging one. It is routine work, not a blocker.

Discharge or transition context

• Where the person is right now – home, hospital, skilled nursing facility, assisted living, a family member’s house.
• Any known date – a discharge date, a facility Medicaid end date, a caregiver leaving on a known day. Waiver enrollment will not usually beat a discharge date, and knowing the date changes what the family is told about bridging the gap rather than waiting.
• What is already authorized – Medicare home health, outpatient therapy, private-pay hours, services under another program.
• Prior waiver history, including any previous EDWP enrollment, denial or disenrollment. A prior denial is better known at intake than discovered at week six.

Consent and authority

• Who has authority to speak for the member: the member themselves, a power of attorney, a legal guardian, a conservator, a healthcare agent. Name them and say which.
• Copies of the instrument, if you already hold them.
• Whatever release your own organization requires to disclose the member’s information. That is governed by your policy and HIPAA, not by ours.

Where nobody has authority and the member cannot consent, say so on the referral. It is a solvable problem, but only if it is known at the start.

What the gaps actually cost

In order of expense: no reachable contact stops everything; unknown Medicaid status can reset the sequence; no functional detail means the assessment starts from nothing; missing clinical documents are routine; an unflagged authority question surfaces at the worst possible moment.

Nothing on this page is an eligibility determination. Only the assessment and Medicaid’s own review decide that.