The Kentucky MAP-10 form, officially the Waiver Services Physician’s Recommendation, is the certification a qualifying provider signs to confirm that a patient would need placement in a nursing facility or intermediate care facility if home and community-based waiver services were not available. It is submitted to the Department for Medicaid Services along with two companion forms, the MAP-109 and the MAP-351, to request prior authorization for waiver services.1Kentucky Legislative Research Commission. 907 KAR 1:160 – Home and Community Based Waiver Services The current version was revised June 2015 and is available as a fillable PDF on the Cabinet for Health and Family Services website.2Cabinet for Health and Family Services. Medicaid Assistance Program Forms
Pick the Right Waiver Program First
The MAP-10 covers five Kentucky Medicaid waivers, and the one you check on the form determines both the eligibility standard the state applies and which providers are allowed to sign.3Cabinet for Health and Family Services. MAP-10 Waiver Services Physician’s Recommendation
- Home and Community Based Waiver (HCBW): Serves individuals who would otherwise need nursing facility care, covering services like personal care, home health aide visits, and adult day health.
- Acquired Brain Injury (ABI) Waiver: Supports individuals with a qualifying acquired brain injury who need structured rehabilitation and daily living assistance.
- ABI Long Term Care Waiver: For individuals with brain injuries who need ongoing, long-term support rather than time-limited rehabilitation.
- Supports for Community Living (SCL) Waiver: Serves people with intellectual or developmental disabilities who would otherwise require placement in an intermediate care facility.
- Michelle P. Waiver: Also serves individuals with intellectual or developmental disabilities, offering community-based alternatives to institutional care.4Cabinet for Health and Family Services. Michelle P. Waiver
Who Is Allowed to Sign
Signature credentials are not the same across the five waivers, and mismatches cause preventable rejections. The form specifies:3Cabinet for Health and Family Services. MAP-10 Waiver Services Physician’s Recommendation
- HCBW: Physician, physician assistant (PA), or advanced practice registered nurse (APRN/PRN).
- ABI Waiver: Physician only.
- ABI Long Term Care Waiver: Physician only.
- SCL Waiver: Physician or an SCL Individually Determined Plan (IDP) provider.
- Michelle P. Waiver: Physician, PA, APRN, or IDP provider.
Check the signature line against the waiver before the provider signs. A PA signature on an ABI Waiver application will come back rejected regardless of how well the PA knows the patient. The signing provider also has to enter a National Provider Identifier (NPI) in the field next to the signature, and should be enrolled in Kentucky Medicaid, because the state cross-references the NPI against its enrollment records during processing.
Filling Out the Form
Download the fillable PDF from the Department for Medicaid Services MAP Forms page.3Cabinet for Health and Family Services. MAP-10 Waiver Services Physician’s Recommendation It is a single page.
Patient and Requestor Information
The top section asks for the patient’s full legal name, Medicaid identification number, Social Security number, and date of birth. Use the name exactly as it appears in the state’s Medicaid eligibility files. A mismatch between the form and the electronic record can delay processing.
At the bottom, the “return to requestor” block takes the requestor’s name, address, city, zip code, and phone number. This is where the state sends the completed determination, so fill every field so correspondence reaches the right office or case manager.
Waiver Selection and Certification Language
The middle of the form asks the provider to identify the waiver and then certify the level-of-care finding. The exact language reads: “I certify that if Waiver services were not available, institutional placement in a Nursing Facility (NF) or Intermediate Care Facility for Individuals with an Intellectual Disability shall be appropriate for this member.”3Cabinet for Health and Family Services. MAP-10 Waiver Services Physician’s Recommendation That is a legal attestation made under the provider’s professional license. The clinical picture the provider documents feeds directly into the state’s nursing facility level-of-care determination.5Legal Information Institute. Kentucky Administrative Regulations 907 KAR 1:160 – Home and Community Based Waiver Services
Signature, NPI, and Date
The provider signs the designated block, writes the NPI, and dates the form. All three are required. An undated signature is one of the most common reasons for rejection, because reviewers treat the date as confirmation that the assessment is current. If the form is being printed and signed by hand, make sure the signature and date are legible; unclear handwriting can trigger a manual review that slows everything down.
The Two Forms That Must Go With It
The MAP-10 is not a standalone submission. Kentucky regulation requires three forms together for a prior authorization request:1Kentucky Legislative Research Commission. 907 KAR 1:160 – Home and Community Based Waiver Services
- MAP-10: Physician’s recommendation certifying the need for institutional-level care.
- MAP-109: Plan of Care and Prior Authorization for Waiver Services, outlining the specific services the patient will receive.
- MAP-351: Medicaid Waiver Assessment, a more detailed evaluation of the patient’s functional abilities and care needs.
Sending the MAP-10 by itself will not open a prior authorization review. All three have to arrive together, and most providers and case managers coordinate to complete them around the same time.
Where to Send It
The three-form package goes to the Department for Medicaid Services. The regulation directs providers to submit the completed MAP-10, MAP-109, and MAP-351 “to the department.”1Kentucky Legislative Research Commission. 907 KAR 1:160 – Home and Community Based Waiver Services Many providers submit electronically through the KY Health Net system, which allows online entry of the information needed for medical necessity review.6Kentucky Medicaid Management Information System. KY Health Net Electronic PA End-User Training Manual Fax submission is available when electronic access is not practical. Contact the Department for Medicaid Services to confirm the current fax number or mailing address, since these can change with contract and staffing transitions.
What Happens After You Submit
Department staff review the documentation to determine whether the applicant meets nursing facility level of care. If anything is missing or the clinical picture is unclear, they will contact the signing provider for additional medical records or clarification. Approval means the patient qualifies for the selected waiver’s services, and providers can begin delivering care and billing Medicaid.
Waiver slots are limited. Several Kentucky waivers maintain wait lists, so meeting the clinical criteria on the MAP-10 does not guarantee immediate enrollment. The form establishes clinical eligibility; an available slot is a separate question.
If the Request Is Denied
The applicant or an authorized representative has 30 days from the date of the denial notice to request a fair hearing. Requests can be filed at a local office or the central office of the Department for Community Based Services, in writing, or verbally with written follow-up.7Kentucky Legislative Research Commission. 907 KAR 1:560 – Medicaid Hearings and Appeals Regarding Eligibility
State clearly why you disagree with the denial and attach supporting medical documentation that was not part of the original submission. If the denial pointed to insufficient clinical detail on the MAP-10, a more thorough narrative from the provider covering the patient’s functional limitations and care needs can strengthen the appeal. The 30-day deadline is firm; a request received after that window is untimely.
Keep a Signed Copy in the Record
Providers who sign the MAP-10 should keep a copy in the patient’s health record. Kentucky regulation requires Medicaid providers to retain recipient health records for at least five years from the date of service, longer if a federal requirement applies or an audit is unresolved.8Kentucky Legislative Research Commission. 907 KAR 3:005 – Coverage of Services and Provider Requirements The MAP-10 is a legal certification that can be revisited during audits or recertification, so the signed original protects both the provider and the patient if questions come up later.