GIS 10 MA/012: New Statewide Form DOH-4471: Certification of Treatment of an Emergency Medical Condition

The purpose of this General Information System (GIS) message is to release the new statewide form DOH-4471, "Certification of Treatment of an Emergency Medical Condition". The new form DOH-4471 replaces upstate form LDSS-3955 and New York City Medical Assistance Program (MAP) form MAP-2151. A copy of the DOH-4471 form is attached to this GIS and is available on line at: http:health.state.nyenet/revldssforms.htm.

All local departments of social services (LDSS) must begin using the new DOH-4471 form effective July 1, 2010, and must discard any existing supplies of the previous versions of the LDSS-3955 and MAP-2151. Providers will be advised via the Medicaid Update that previous versions of the LDSS-3955 and the MAP-2151 are no longer acceptable and that submission of either of these forms after June 30, 2010, may result in a delay in payment.

The most significant change to the new form is the "Authorization to Release Medical Information" section. The "Authorization to Release Medical Information" section has been moved to the reverse side (side 2) of the form. The DOH-4471 includes both the English/Spanish translation of the authorization to release medical information. Instructions to the provider on how to complete the new DOH-4471 form have also been added to side 2. The DOH-4471 must be issued as a two-sided rather than a two-page document and must not be modified.

The DOH-4471 certification form must be signed by the applicant/recipient (A/R). If the A/R is unable to sign the certification form, his or her authorized representative may sign on behalf of the A/R. The form is not valid without the required signature of the A/R or his/her authorized representative. Signing the DOH-4471 authorizes the LDSS to request information regarding the emergency medical treatment. It also gives the physician or facility permission to provide such information. The treating physician must complete the DOH-4471 and sign and date the form. The physician must, in all cases, make the decision as to whether or not the medical treatment is for an emergency medical condition. Each DOH-4471 form must be retained in the recipient's case file.

The DOH-4471 form has space to accommodate up to four coverage periods (From-To Date(s) of Treatment/Hospital Stay). Each "From-To" date(s) must be entered in the Welfare Management System (WMS) as a separate coverage period, and each coverage period requires a separate Client Notification System (CNS) notice (upstate). NYC manual notice instructions have been issued under separate cover. For any subsequent treatment/hospital stay or continuing treatment for an emergency medical condition, a new DOH-4471 form must be completed, dated, and signed by the A/R, or the A/R's authorized representative, and by the treating physician

The care that can be covered by Medicaid under the definition of an emergency medical condition is time limited and date specific; authorizations for emergency care must include a specific period of time in the past (i.e. at least one day prior to the date of the initial Medicaid application or one day prior to the Transaction Date for recipients in need of continuing care for the treatment of the emergency medical condition). This is because an emergency medical condition by definition is unexpected with sudden onset that requires immediate medical treatment. Medicaid coverage for the treatment of an emergency medical condition starts on the day treatment for the emergency was initiated and ends when the emergency medical condition is no longer an emergency.

The maximum period of time for which "emergency treatment" (coverage code "07") may be entered from one submission of the DOH-4471 form is 90-days. This can be a combination of retroactive, current and prospective coverage. A new DOH-4471 must be obtained from a physician at least once every 90 days, in order to continue the Medicaid coverage. Future (prospective) coverage may not exceed 60 days.

The social services district must notify the provider of the authorization of coverage, the period(s) of coverage and the individual's Client Identification Number (CIN).