GUIDELINES FOR NURSING FACILITY NOTICES FOR by pptfiles

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									GUIDELINES FOR NURSING FACILITY NOTICES FOR ELIGIBILITY DETERMINATION

The information in this manual is based on the Code of Federal Regulations (CFR) for Nursing Homes, the Standards for Payment for Nursing Homes, DHH/BHSF policies/procedures/best practices and the BHSF/Medicaid Parish Office for financial eligibility procedures.

Re-issued January 2008

Table of Contents Abbreviation Key Definitions Nursing Homes Introduction for Nursing Homes NOTES Appendix Quick Reference Tool For Submission Of Admission Packets To OAAS and Local Medicaid Eligibility Office PASARR Form Instructions 7 13 3 4

A. B.

A B

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Abbreviation Key BHSF – Bureau of Health Services Financing CFR – Code of Federal Regulations DHH – Department of Health and Hospitals DD – Developmental Disability Dx – Diagnosis Eval- Evaluation ID – Infectious Disease LISP – LOCET Individual Summary Page LOC - Level of Care LOCET – Level of Care Eligibility Tool LOCET FS – LOCET Face Sheet LTC - Long Term Care MEO – BHSF Medicaid Eligibility Office (Financial Eligibility) MI – Mental Illness MR – Mental Retardation MR/DD – Mental Retardation/Developmentally Delayed NRTP – Neurological Rehabilitation Treatment Program NH/NF – Nursing Home/Nursing Facility OAAS – Office of Aging and Adult Services OMH – Office of Mental Health PASARR or PAS/RAS (Level I form) – Preadmission Screening/Re-admission Screening SFP - Standards for Payment SMS – Statement of Medical Status SNF –Skilled Nursing Facility TDC – Technology Dependent Care VA – Veterans Administration Contract

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DEFINITIONS (For the purposes of this manual) Applicant – A person who applies for a program administered by the Department of Health and Hospitals. Benefit Period – The interval of time allocated for services under a specific Medicare program or a Medicaid program /level of care, i.e., 1. Medicaid hospice benefit periods are limited to two 90 day periods per lifetime that must be used first; each subsequent 60 day period requires Medicaid Prior Authorization Unit approval. 2. NRTP Rehabilitation or NRTP Complex is limited to an initial period not to exceed 90 days; extensions may be requested in 30 day increments, up to a maximum of three extensions - cannot exceed a total of six months. 3. Medicare skilled benefit periods are 100 days (20 days at 100% coverage and 80 days at 80% coverage). Break in Institutional Care - An interruption in a person’s NF stay which occurs anytime he/she is discharged from a nursing facility, ICF/MR or hospital and resides for 24 hours or more in a setting other than in a nursing facility, an ICF/MR, or a hospital. This also occurs when a person has a home leave stay of more than 30 continuous days. (LA Register, Vol. 24, No. 5, May 20, 1998) Conversion to Medicaid – The initial conversion to Medicaid from any other payor source as referred to in LA Register, Vol. 32, No. 08, November 20, 2006 which refers to this conversion as a new admit to Medicaid Benefit period. Direct Transfer – Refers to the transfer of a resident from one Medicaid/Medicare, or dually certified nursing facility to another without a break in institutional care or services. This includes NH to hospital to NH transfers. Discharged – The status for any person who is no longer being treated in a Medicaid/Medicare nursing facility or hospital. There is a break in institutional care. The person has exited the facility, will be coded as such on the billing document, and his/her bed is available for another person. Discontinue billing – The process of stopping any type of per diem billing for a person’s non-billable absence from the facility. The person’s bed is held for the person’s anticipated return to the facility. Eligibility determination for Medicaid – This encompasses the determination of a person meeting the established medical criteria and financial criteria to qualify for Medicaid funding benefits. The Department of Health and Hospitals/Office of Aging

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and Adult Services is responsible for the medical eligibility determination for persons entering a nursing home. The BHSF/Medicaid Eligibility Office is responsible for initial and on-going financial eligibility determinations and the determination of a resident’s liability for facility care. Extension – A request for continued nursing facility services/eligibility following a temporary benefit period. Intake Analyst – Specially trained personnel within Louisiana NFs and/or OAAS contractors or designees, who administer LOCET to applicants or their personal representatives. Level of Care Change – A change in the Medicaid Level of Care allocation previously submitted/approved by OAAS. This is only applicable to a resident occupying a Medicaid bed (case mix, ID, TDC, NRTP). This includes return to case mix. Note: for the purposes of this manual, status changes between Medicare and Medicaid are payment source changes, not a change in level of care. Level of Care Eligibility Tool –LOCET is a scientifically developed and research-based evaluation tool utilized to determine Nursing Facility Level of Care. The LOCET is required in conjunction with additional assessment and screening tools as specified by DHH for entry to all programs requiring a Level of Care determination. LOCET establishes uniform criteria that serve as the determination for level of care for all long-term care services requiring such a level of care. LOCET Individual Summary Page (LISP) A summary page printed for each LOCET administered. It will list the pathway of eligibility (if any), the status of the LOCET, and submits important information needed. LOCET Face Sheet (LOCET FS) – Summary which contains identifying and contact information for applicant. New Admission– A person entering a Louisiana Medicare/Medicaid nursing facility for the first time with no previous admission to the same type of facility within the State of Louisiana. Medicaid Eligibility Office -The BHSF/Medicaid Eligibility Office is responsible for initial and on-going financial eligibility determinations and the determination of a person’s liability for facility care.

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PASARR or PAS/RAS Level I – (Preadmission Screen/Annual Resident Review or Re-admission Screening) Federal regulations require all individuals requesting admission to a NF or current NF residents experiencing a significant change in condition be screened prior to admission, readmission, or following a significant change affecting the active treatment of mental illness and/or mental retardation. In order to meet this requirement, an initial or subsequent LEVEL I screening is required regardless of the applicant’s payor source. Personal Representative – A person who represents the interests of the applicant who is not capable of self-direction. The function of the personal representative is to accompany, assist, and represent the applicant in the program evaluation process, and to aid in obtaining all necessary documentation for the agency’s evaluation for services. The personal representative has been authorized by applicant to make decisions for the applicant concerning all aspects of various programs administered by DHH. Private pay – Any vendor payment source other than Medicaid funds (Medicare, insurance, private funds, VA contract, etc.). Qualifying stay for Medicare benefit period in a NH: A hospital stay involving at least three consecutive midnights within the prior 30 days must occur in order to qualify for a Medicare or Medicare with Medicaid co-pay benefit period in a NH. Re-admit – Any person re-entering a Louisiana Medicaid/Medicare nursing facility following a break in institutional care or discharge from the same type of facility within the State of Louisiana. Resident – Any person residing in and/or receiving treatment in a NF. Resident Returned – Any resident/person who returns to the Nursing Home after billing discontinued on the billing document (resident was not discharged). Statement of Medical Status (SMS) -A form designed to document the current medical status of a person entering a nursing facility. It must be completed by a Louisiana licensed physician and/or his/her licensed designee with the signature date on or not more that 30 days prior to the date of admission/application. (Effective Dec. 1, 2006 – The 90L will no longer be an accepted form for NF admission). Temporary Admission – A time-limited stay in a Medicare/Medicaid nursing facility based on medical necessity and/or Level II results.

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UNISYS – The fiscal intermediary for facility billing for Medicaid eligible persons in a nursing facility. INTRODUCTION FOR NURSING FACILITIES

Code of Federal Regulations (CFR) require the screening of all individuals with mental illness or mental retardation/developmental disabilities/related conditions who apply to reside or already reside in Medicaid certified nursing homes, regardless of the source of payment. To meet this requirement, an initial PASARR preadmission screening is required of all individuals with MI/MR-DD seeking admission to or readmission following a break in institutional care -regardless of payor source or known diagnosis. Subsequent Level I PASARR screening is required for any current MI/MR-DD resident experiencing a significant change requiring referral to the State’s Level II authority. After meeting medical/LOCET eligibility, if it is determined that the individual does meet criteria, an in-depth evaluation (Level II) screening will be completed. For applicants/residents requiring initial preadmission Level II categorical approval, the NF is responsible to seek prior approval through OAAS. Without prior approval, FFP will be available only for services furnished after the Level II determination has been completed and approved. Existing residents, who are determined to meet the criteria of I. B.2 below, will also be subject to Level II screening. The nursing facility is responsible for prompt notification of the significant change requiring PASARR review and Level II referral. I. Level I Screening The CFR offers the following guidance at 483.128 PASARR Evaluation Criteria: “Level I: Identification of individuals with MI or MR. The State’s PASARR program must identify all individuals who are suspected of having MI or MR as defined in 483.102. This identification function is termed Level I. Level II is the function of evaluating and determining whether NF services and specialized services are needed. The State’s performance of the Level I identification function must provide at least, in the case of first time identifications, for the issuance of written notice to the individual or resident and his or her legal representative that the individual or resident is suspected of having MI or MR and is being referred to the State mental health or mental retardation authority for Level II screening.” In order to meet the State’s responsibility, the following process is to be followed. A. All new nursing home admission, readmissions, initial private to Medicaid conversion, and extensions, must include a PASARR Level I Screening . A physician (licensed in Louisiana) must complete, sign, and date the PASARR. The PASARR

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consists of seven questions and mental status information regarding mental retardation and developmental disabilities, and mental illness including a section related to the Diagnosis, Disability, and Duration of mental illness. (Note: If the physician who completes the PASARR - I is not licensed in Louisiana, the PAS/ARR may be used for screening of the need for Level II only and not for admission purposes. Seek authorization and prior approval through OAAS for out-of-state applicants). The Level I information is reviewed by an OAAS professional to determine the need for a Level II screening. The information on the Level I form must be supported by the diagnoses and medications listed on the SMS and vice versa. B. A Level I PASARR assessment and review is required for: 1. New admissions to a nursing facility and any re-admissions following a break in institutional care, and initial conversions from private pay or other non-Medicaid funding to Medicaid, and requested Medicaid extensions. 2. Any current NF resident who has experienced a significant change in condition requiring a Level II assessment and evaluation, e.g., resident was in a psychiatric hospital or unit, resident is now receiving pschyotrophic medicine due to a mental illness not previously treated, and was not diagnosed prior to hospitalization, there was a significant change in behavior related to the mental illness diagnosis that precipitated the hospital admission, or a significant change in the resident’s health status which has a bearing on his/her active treatment needs. See Code of Federal Regulations and La. Register regarding requirements for new PASARR. II. Level II Screening: A. If the applicant’s/resident’s medical information reviewed during the Level I process indicates an answer of “yes” to questions 1 and/or 2 for Mental Retardation or Developmental Disability, and/or the person meets the 3 D’s of Diagnosis, Disability, and Duration for Mental Illness on the Level I form, a Level II screening is required to determine if nursing facility placement or continued placement is appropriate and/or the need for specialized services for the condition/diagnosis. Note: See appendix “B” for complete instructions for PAS/RAS (PASARR) Level I & II screening requirements. B. Documents to be submitted by the nursing facility if a Level II is warranted: Form 148, a current SMS, PASARR, Physician admit order, LOCET, History and Physical, the most current psychiatric evaluation (mental illness), Psychological evaluation (mental retardation), psychosocial assessment (mental illness) the Social History (Mental

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Retardation), any other consultation reports, CAT scans/MRI reports if available, and significant physician progress note. Note: If a Dementia diagnosis exists in addition to a mental illness or a mental retardation/developmentally delayed diagnosis, submit documented evidence (including, but not limited to: Dementia evaluation, psychiatric evaluation, neuropsychological evaluation, etc.) which clearly identifies and supports the diagnosis of Dementia. If Dementia is submitted as the primary diagnosis with a major mental illness as secondary, the applicant’s/resident’s current medical and /or psychiatric evaluations must identify the Dementia as the primary diagnosis or a LEVEL II determination will be required. C. By review of the medical record, SMS and LEVEL I PASARR, and/or other medical records on a new admission/readmission/or current resident, the nursing facility will identify triggers for the need for an initial or subsequent Level II assessment (See appendix B) and submit a complete prescreen packet to OAAS for new admissions or readmissions or promptly notify OAAS of a significant change in a current MI/MR_DD resident requiring PASARR review. (Documents to include in the packet are covered in II. B. above). When submitting a pre-screen packet to OAAS, indicate on the top of the 148 “PRE-SCREEN FOR MEDICAL AND/OR LEVEL II.” After review of the pre-screening packet, if OAAS has determined that a 30 day Advanced Group Placement pending the results of the Level II is indicated, OAAS will issue prior approval to the nursing facility. For vendor payment eligibility to be retroactive to the admission/readmission date, the nursing facility must seek preadmission screening and prior approval from OAAS. Once admitted, the nursing facility will submit the admit Form 148 to OAAS for initiation of the Level II. Final placement determinations and/or resident’s choice to remain in the nursing facility are contingent upon the Level II authority’s determination and/or a current resident’s length of residency according to the Code of Federal Regulation. (Note that for initial admissions or readmission following a break in institutional care, if the applicant fails to meet Nursing Facility Level of Care for admission/readmission, an Advanced Group Placement will NOT be approved). D. In certain rare circumstances, after review of a pre-admission screening packet, OAAS may determine that a Level II assessment and determination by the State’s Level II authority is required PRIOR to admission. When this occurs, OAAS will NOT grant a 30 day Advanced Group Placement. OAAS will submit a pre-screen packet for Level II prior to admission/readmission. Once a final determination by the state’s Level II authority has been made, OAAS will submit the results to the appropriate parties involved. If a Level II screening evaluation, completed prior to

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admission/readmission, results in approval for NH placement, the approval must be acted upon by the applicant within 30 days of the date on the Level II approval. If not admitted to a nursing home within that period, the approval is void. If this occurs, a determination of medical and Level II eligibility must be reestablished. E. If the Level II determination results in denial of nursing facility placement or continued stay, the applicant has 30 calendar days from the date of cover letter notification of Level II results to appeal. Level II authority contact information and Fair Hearing Rights are included within the report submitted by the respective Level II authority (OMH/OCDD). F. Transfers between nursing homes (even if a hospital stay is involved between the transfer from the prior NH and admission to the receiving NH), the prior NH is responsible for providing the receiving NH with a copy of any existing Level II determination (if institutional care was not broken) and should include the OMH and/or OCDD decision form and OAAS’ Level II cover letter/notification of results. G. If institutional care is broken, any prior Level II screening is void. Level II screening will need to be repeated, if Level II criteria is met.

III.

Level of Care Medical Certification for Nursing Facility/Nursing Home (NF/NH) Admission All individuals admitting to a Medicaid Certified NF will need a completed Level of Care Eligibility Tool (LOCET), regardless of payor source. When an individual is admitted to a NF and Medicaid is the intended payment source for the services provided, a medical certification evaluation (LOCET) must be performed to determine if the resident meets the established criteria for admission to a Louisiana nursing facility. A complete admission packet (see Appendix A) includes a 148, SMS, MD order, PASARR Level I, and a LOCET. All 5 components must be complete, signed and dated. For admission into a Louisiana Medicaid/Medicare certified nursing facility, the applicant must have physician orders and a PASARR Level I form completed and signed by a physician licensed to practice in the state of Louisiana –dated on or within 30 calendar days prior to admission/application. The LOCET must be completed by intake analyst trained by the Louisiana Department of Health and Hospitals, Office of Aging and Adult Services. The SMS must be completed by a Louisiana licensed physician and/or licensed designee (RN, LPN, PA, NP). The physician’s order and PASAR must be dated on or within 30 days prior to admission/application. Medical certification for Medicaid cannot be granted earlier than the date of the Louisiana physician’s

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signature on the admission order and/or PASARR I form. PASARR Level I is required regardless of payor source or known diagnosis. I. The following procedure is to be utilized: Time Lines: New Admission, Readmission, Extensions, Private to Medicaid Conversions, (see Appendix A) The provider must complete a Level of Care Eligibility Tool (LOCET) as directed in the LOCET User Intake Manual and Appendix A of this manual. A. The Provider must submit a complete packet (Appendix A) of information for review to the OAAS within 20 working days of application or admission (excluding week-ends and state holidays). A medical eligibility for Medicaid benefits determination will be made by an OAAS professional. (Louisiana Register, Vol. 23, No. 10, October 20, 1997 and subsequent revisions) B. If an incomplete admission/application packet is received, OAAS will request the missing information. If the requested information is received after the 20 th working day, the date of vendor payment eligibility becomes the date the complete packtet is received by OAAS. If the 20 working days have elapsed and OAAS has not received the requested infoemation, a Medicaid medical eligibility benefits determination cannot be made. Where this occurs, a Form 142 will be issued as “Not approved” – Unable to make a determination because complete admission packet was not received timely.
C.

If the requested information is received prior to the 20th working day, vendor payment will be retroactive to the date of admission/application.

IV.

Change in Level of Care (LOC) (see SFP/Louisiana Register and subsequent revisions): The provider shall be responsible for submitting a request for LOC change to OAAS when it is determined by the attending physician that the resident is no longer at the LOC previously certified by OAAS. A 148, current SMS, and MD order form shall be submitted when making the request for a change in LOC. Additional information may be requested by OAAS if necessary. The complete packet is due on or within 20 working days of application. If the facility fails to submit the request information within the 20 working days, the earliest date of vendor payment will be the date the completed packet is received by OAAS. LOC changes involve case mix, NRTP, TDC & ID within the Medicaid program.

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V.

VA Contracts For VA contract admissions to the NH, the applicant is also subject to the regulations regarding Level I and Level II screening. If the admission is a VA contract, a VA FORM 1204 – REFERRAL FOR COMMUNITY NURSING HOME CARE may be substituted for the SMS. The LEVEL I SCREEN FOR PRE-ADMISSION OR RE-ADMISSION SCREENING (PASARR) FORM is also required. If the VA recipient wants to apply for Medicaid benefits for continued stay in the NH beyond the VA contract interval, a complete packet, including a LOCET, for conversion to Medicaid must be submitted to OAAS on or within 20 working days of application. Hospice See SFP/Louisiana Register and subsequent revisions – Hospice and Minimum Standards for Licensing of Hospice Agencies The nursing home and the hospice agency must have a contract delineating the responsibilities of each entity. (See Appendix A)

VI.

VIII. Technology Dependent Care (TDC) See the SFP/Louisiana Register and subsequent revisions, if any, for criteria for this LOC. The facility needs to submit documentation to support the criteria for this LOC, i.e., number hours on the ventilator/24 hours, ventilator settings. IX. Infectious Disease (ID) See the SFP/Louisiana Register and subsequent revisions, if any, for the criteria of the various SN – ID levels of care and submit documentation accordingly. Neurological Rehabilitation Treatment Program (NRTP) - Rehab/Complex See the SFP/Louisiana Register and subsequent revisions, if any, for the criteria of the rehab and complex NRTP level of care and submit documentation accordingly. Also see Louisiana Register, Vol. 23, No. 8, August 20, 1997 and subsequent revisions for amendments. See Benefit Period definition for time limits.

X.

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NOTES For your convenience, please note any future directives or publications from DHH/BHSF/OAAS or the Centers for Medicare and Medicaid Services which will affect the information within this manual. This will aid you in keeping the most current information available for your facility staff. Date Source of Information Topic

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