The NC Medicaid DHB-3051 form is the practitioner-signed request that triggers an independent assessment for Personal Care Services (PCS) — in-home help with bathing, dressing, eating, toileting, and mobility. To use it correctly, download the current September 18, 2024 version, complete the beneficiary, medical, and practitioner sections with ICD-10 codes that map to the specific ADL deficits, sign it by hand, and fax it to Acentra Health. Submitting an older version on or after April 1, 2025 will delay processing.1NC Medicaid. Personal Care Services
Download the Current Version
Get the form from the NC Department of Health and Human Services “Request for Services and Instructions” page. The download packet includes the form and step-by-step instructions.2NC Medicaid. Request for Services and Instructions (DHB 3051) Confirm the footer reads September 2024. Copies stored on third-party sites or older provider intranets may be prior editions, and Acentra Health, the state’s current assessment contractor, will reject them.
Who Qualifies Before You File
PCS is for people with a medical condition, disability, or cognitive impairment who have unmet needs in Activities of Daily Living. NC Medicaid recognizes five ADLs: eating, dressing, bathing, toileting, and mobility. A beneficiary qualifies by meeting one of three thresholds:1NC Medicaid. Personal Care Services
- Needs some hands-on help with at least three of the five ADLs.
- Needs help with two ADLs, and at least one requires extensive physical assistance.
- Needs help with two ADLs, and at least one means full dependence — the beneficiary cannot participate at all.
Cognitive impairment counts toward the underlying condition. A dementia diagnosis, traumatic brain injury, or intellectual disability can establish the medical basis; the ADL deficits those conditions cause are what the assessor scores. The form itself does not determine eligibility — it triggers the independent assessment that does.
Section A: Beneficiary Information
Enter the beneficiary’s full legal name, date of birth, and Medicaid Identification Number (MID) exactly as they appear on the Medicaid card.3Partners Behavioral Health Management. NC Medicaid Personal Care Services Form DHB-3051 One wrong digit in the MID will keep the system from matching the request to the beneficiary’s account. If the beneficiary is enrolled through an LME/MCO or Standard Plan, fill in the RSID number and date in the fields marked for ACH-only submissions.
Section B: Medical Conditions and ADL Deficits
This section is where most rejections start. List each diagnosis with the complete ICD-10 code, and make sure every code connects to the ADL deficit being claimed.3Partners Behavioral Health Management. NC Medicaid Personal Care Services Form DHB-3051 A hypertension code will not support a request for bathing assistance unless you tie it to a functional limitation such as fall risk or severe dizziness in the shower.
Then describe, in clinical terms, how the conditions prevent the beneficiary from performing each daily task independently. “Patient needs help” is not enough. Spell out the specific physical or cognitive deficit and map it to the ADL. If the beneficiary has both physical and cognitive impairments, document both. The independent assessor uses the full picture when scoring.
Section C: Practitioner Information and Signature
Enter the practitioner’s name, practice address, phone, fax, and National Provider Identifier (NPI).4Trillium Health Resources. NC Medicaid Personal Care Services Form DHB-3051 A practice stamp is acceptable for the address and contact fields. The signature is not: it must be handwritten, and signature stamps are not allowed.3Partners Behavioral Health Management. NC Medicaid Personal Care Services Form DHB-3051 Date the form the same day you sign it. That signature makes the document a medical order certifying that the clinical information is accurate and based on a direct evaluation.
Section D: Only for a Change of Status
Leave Section D blank on an initial request. Use it only when a beneficiary already receiving PCS has had a medical change that justifies a new assessment — a stroke, a new diagnosis, or a significant decline in function. Describe the medical event and how it has changed the beneficiary’s ability to perform ADLs since the last assessment.
Where to Submit
Fax the signed form to Acentra Health, which operates the NC LIFTSS system and replaced Liberty Healthcare as the state’s Comprehensive Independent Assessment Entity in 2023.1NC Medicaid. Personal Care Services Current contact information:
- Fax: 833-521-2626
- Phone: 833-522-5429
- Portal: ncliftss.acentra.kepro.com
Older handbooks and provider references still list Liberty Healthcare’s fax numbers. Those will not reach the right place. Keep a copy of the signed form in the beneficiary’s permanent medical record, and give a copy to the beneficiary.
What Happens After You Submit
The form does not approve services. It triggers an independent assessment, typically an in-home visit by a nurse who evaluates each of the five ADLs and scores the level of assistance the beneficiary needs. That assessment, not the form, determines whether PCS is approved and how many hours are authorized.1NC Medicaid. Personal Care Services NC Medicaid does not publish a guaranteed scheduling window, so the wait between submission and the visit varies with volume. Once complete, the beneficiary receives a written notice with the number of approved hours or a denial with appeal instructions.
PCS hours are capped at 130 per month.5NC Medicaid. 3L, State Plan Personal Care Services (PCS) The actual number depends on assessment scoring. After approval, the provider accepting the referral must develop and validate a service plan in NC LIFTSS within seven business days, and the beneficiary or their legally responsible person must sign it within 14 business days. No prior authorization is issued until that service plan is entered and validated.6NCLIFTSS. PCS Provider Manual
Renewing Before the Annual Anniversary
Authorizations are not permanent. The state’s system checks whether each beneficiary has had an independent assessment within the past year. If the anniversary passes without a reassessment, the authorization ends that month.1NC Medicaid. Personal Care Services Submit a renewal DHB-3051 well before the anniversary date to avoid a gap in services.
Why Forms Get Kicked Back
Most delays are avoidable paperwork problems:
- ICD-10 codes that do not match the ADL deficit being claimed.
- A wrong or transposed MID number.
- An outdated version of the form.
- A signature stamp instead of a handwritten signature.
- A thin medical-necessity narrative that gives the assessor nothing to score.
If the beneficiary has multiple contributing conditions, document all of them with the corresponding ICD-10 codes. Five minutes on a detailed clinical narrative in Section B saves weeks of back-and-forth after submission.
If the Request Is Denied
A denial or a lower-than-expected hours award comes with a written notice. The beneficiary has 60 days from the date on that notice to file an appeal. For beneficiaries already receiving PCS who face a reduction or termination, the window to request continuation of services during the appeal is much shorter — generally 10 calendar days from the date the notice is sent.7Vaya Health. NC Medicaid Direct Member Appeals A standard appeal decision takes up to 30 days. If a delay could seriously jeopardize the beneficiary’s health or ability to function, request an expedited appeal, which must be decided within 72 hours. If the appeal upholds the decision, the beneficiary can request a state fair hearing for an independent review outside the managed care plan.