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This document outlines the State Plan under Title XIX of the Social Security Act for Virginia, detailing the case management services provided to Medicaid eligible individuals, particularly for high-risk
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01
Obtain the HCFA-PM-87-4 form from the appropriate source or website.
02
Fill in the patient's information, including name, date of birth, and social security number.
03
Provide details about the provider, including name, address, and contact information.
04
Specify the services being requested by entering appropriate codes and descriptions.
05
Indicate the duration of services needed and any additional relevant information.
06
Review the form for completeness and accuracy.
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Sign and date the form at the designated section.
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Submit the completed form according to the instructions provided.

Who needs hcfa-pm-87-4?

01
Individuals who require Medicaid services.
02
Healthcare providers seeking reimbursement for services rendered.
03
Patients needing to document their eligibility for certain health services.
04
Medicaid administrators managing service authorizations and claims.
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HCFA-PM-87-4 is a form used by state Medicaid agencies to request approval for changes to their Medicaid programs, particularly regarding new or modified benefits.
State Medicaid agencies are required to file HCFA-PM-87-4 when they wish to make changes to their Medicaid programs that require federal approval.
To fill out HCFA-PM-87-4, agencies should provide detailed information about the proposed changes, including the rationale, the impact on beneficiaries, and any relevant data supporting the request.
The purpose of HCFA-PM-87-4 is to provide a standardized process for states to seek federal approval for modifications to Medicaid programs, ensuring compliance with federal guidelines.
Information reported on HCFA-PM-87-4 includes the specific changes being requested, the reasons for these changes, projected costs, and the affected population segments.
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case management Medicaid services Virginia state plan high-risk pregnant women children services mental health targeted case management social services health care coordination provider qualifications

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