Form 2362, Receipt Certification by a Qualified Rehabilitation Professional

Instructions

Updated: 9/2020

Purpose

Form 2362 assists nursing facilities (NFs) in reimbursement for the durable medical equipment (DME) supplier’s qualified rehabilitation professional (QRP) to be present and involved in the clinical assessment for a customized manual wheelchair (CMWC) through the Preadmission Screening and Resident Review (PASRR) program. At the time the CMWC is delivered, the QRP must ensure the chair meets the needs and proper fitting for the resident.

When to Prepare

For an NF to be reimbursed, Texas Health and Human Services Commission (HHSC) requires the QRP to complete Form 2362 after the CMWC is delivered. The NF submits the form, along with the PASRR NF Specialized Service (NFSS) - CMWC/DME Receipt Certification (PDF), on the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Online Portal (LTCOP). Submitting these two forms allows HHSC to make the funds available to the NF by creating the service authorization. After HHSC reimburses the NF, the NF will pay the DME provider for the chair and the QRP assessment.

Detailed Instructions

Form 2362 is completed upon receipt of the CMWC. The authorizing NF therapist must coordinate with the QRP to verify that the QRP was present and involved in the clinical assessment for the CMWC and that the CMWC meets the needs of the resident and that the specifications are as intended. Form 2362 must be uploaded to the LTCOP by the NF after delivery and certification to receive a service authorization for the CMWC. Failure to submit Form 2362 will delay the facility's reimbursement for the item.

Alterations to this form makes it invalid. Examples of alterations that invalidate this form include the use of white out, cutting and pasting, and blacking out information. Alterations will result in the request being placed into a pending denial status or denied. Errors may be corrected by drawing a single line through a mistake, writing the correction next to it, and initialing and dating the correction instead of making alterations to the form.

For detailed instructions on how to attach completed forms to a Nursing Facility Specialized Services (NFSS) form on the TMHP LTCOP, refer to the Companion Guide for Completing the Authorization Request for PASRR Nursing Facility Specialized Services (PDF).

Complete all fields before uploading Form 2362.

Individual’s Name – Enter the first and last name of the person receiving the CMWC.

NFSS Document Locator No. (DLN) – Enter the DLN generated by the TMHP LTCOP for the CMWC request.

Medicaid ID – Enter the Medicaid number for the person receiving the CMWC.

QRP First Name – Enter the first name for the QRP performing the assessment.

QRP Last Name – Enter the last name for the QRP performing the assessment.

QRP Certification No. – Enter the certification number for the QRP performing the assessment.

QRP Certification Date – Enter the date the QRP certified the CMWC meets the needs of the person receiving the CMWC.

QRP’s Signature – The QRP signs the form to certify that the QRP was present and involved in the clinical assessment for the CMWC and that the CMWC meets the needs of the person receiving it. Note: To avoid requests being put in pending denial or denied status, the QRP must ensure the signature and signature dates provided are accurate and verifiable. All signatures must be original, handwritten signatures. HHSC will not accept typed, copied or stamped signatures. HHSC will only accept digitally signed signatures if they contain a date/time stamp.

Date – The QRP enters the date of signature.