The CMS 485 Plan of Care form is required to be submitted by a provider for the authorization of private duty nursing (PDN) services. NC Medicaid requires a physician’s signature and date of signature on each page of the form.
Effective May 1, 2023, the physician signature and date of the signature are only required on the first page of the CMS 485 Plan of Care form (sections 9 and 10).
Providers are to ensure each page of the form and any attachments or addenda contain the information noted in sections 1 – 7 of the form.
The signed physician’s orders documented on the first page apply to all pages of the CMS 485 Plan of Care as well as any attachments or addenda.
The CMS 485 Plan of Care form can be accessed at:
medicaid.ncdhhs.gov/providers/forms/private-duty-nursing-forms/
Contact
Medicaid.HomeCareService@dhhs.nc.gov