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Medicare 486 Form: What You Should Know

Plan of Care 1. Form 8942 (with Explanation and Disclosures) (J079) 2. Application for Certification by Provider: 486 487 489 490 3. Copy of Home Health Care Provider Plan of Care for the Patient (J079) Note. A list of the name(s) of the Health Care Providers who have accepted or are working with the patient may also be included. Mental Health Evaluation and Treatment (MEET): Reimbursement Form for Psychiatric Benefits Covered. A copy of the completed MEET form. Medicare (CHIP)/Medicaid (MCO) 468 and 487 Treating Mental Illness. Medicaid Benefits Covered: Mental Health Evaluation and Treatment. 468, 487 The first step in mental health treatment is determining the extent and nature of a patient's mental illnesses and/or disorders. The mental health evaluation and treatment is a process in which a healthcare provider evaluates your mental health and your treatment strategy using the clinical assessment, diagnostic test(s) and appropriate therapeutic protocol(s). CMA CFO CMI Form 902 CFA CMI Form 903. CFA Form 903 may be used by any person who has applied for Medicare Part A or Section 1116 Medicare Part B services and has not received the service yet, or those beneficiaries whose disability insurance or Medicare Part B coverage covers treatment up to the same date and location as the part B services. The CFA Form 903 is a complete self-report form covering the time period for which payment has been allowed by Medicare for the part A services. An original CFA Form 903 is needed at each time that services are provided, including when the services are in-patient and out-patient or, in the case of out-patient services, when they are provided at a different location from the part A services. Any copy of the CFA Form 903 that has been lost may be replaced by either a completed and returned CFA Form 903 or a previously completed copy of the CFA Form 903. When completed and returned, the CFA 903 will contain the complete information needed for the Medicare determination. If submitted, CFA Form 903 will not be a part of a claim but rather will be used by the beneficiary to provide for payment of the part A services.

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