Form 3672, Medicare/Medicaid/Third-Party Resources Utilization Report

Effective Date: 12/2010


PDF: 3672.pdf


Updated: 12/2010

Home and community support services (HCSS) and managed care organization (MCO)-contracted providers must attempt to purchase all items listed on the individual service plan (ISP) from Medicare, Medicaid, or other third-party resources before billing Community Based Alternatives (CBA)/the MCO.


  • To serve as a prompt to CBA/SPW providers for action needed to comply with CBA/SPW policy regarding utilizing Medicare and Medicaid home health benefits and other third-party resources for medical supplies and adaptive aids listed on the ISP.
  • To serve as an item-specific verification document for the utilization of Medicare and Medicaid Home Health Benefits before billing CBA or the MCO for payment.
  • To serve as proof of attempt to purchase items through Medicare and Medicaid.
  • To document pending Medicare/Medicaid benefits approval or denial of items on the ISP.
  • To inform the case manager/MCO of the Medicare/Medicaid resource that will be used to purchase needed medical supplies or adaptive aids.
  • To explain why a CBA/SPW applicant/individual/member is not homebound. Note: Must always explain why an applicant/individual/member is not homebound.
  • To document the referral to another Medicaid contracted agency when the provider is not a contracted Medicaid provider.
  • To document the utilization of other third-party resources.


When to Prepare

  • HCSS/MCO-contracted providers complete this form at the initial assessment and the annual assessment.
  • It will also be completed for special request items not in the CBA Provider Manual.
  • It will be completed when a service plan change is requested for medical supplies or adaptive aids.


  • The original is sent along with the initial packet, the reassessment packet, and ISP change packet to the case manager/MCO.
  • The provider must submit clear, concise documentation of denial or approval of Medicare/Medicaid/TPR on this form before sending to the case manager/MCO. The case manager/MCO reviews this documentation before sending to the regional nurse.
  • This form is to completed in full, signed, and dated by the appropriate HCSS/MCO-contracted provider staff.
Top of Page