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PREADMISSION REVIEW
Preadmission review is a process that applies to most individuals seeking access to Medicaid funded long-term care. The purpose is to ensure that people receive the care they need in the most appropriate, least restrictive setting.
Preadmission review includes 2 major components, preadmission screening (PAS) and level of care (LOC). One or both parts can be required.
PAS – Is the process for screening individuals for indications of serious mental illness and/or mental retardation or developmental disabilities. It is required for all admissions to Medicaid certified NF’s, regardless of the payment source.
- This is a federal mandate. All PAS requirements must be met before a level of care determination can be made for an individual seeking Medicaid as their primary payment source.
LOC – Is a designation of an individual’s functional and nursing needs pursuant to the requirements and criteria in the Ohio Administrative Code (OAC) rules.
- level of care determination is required for individuals seeking Medicaid vendor payment in a Medicaid certified NF or Medicaid waiver program and for individuals enrolled in the RSS or PACE program
- an intermediate or skilled level of care is required for Medicaid vendor payment in a NF. It is also one of the eligibility requirements for PASSPORT home care, Assisted Living Waiver and PACE enrollment
- a protective or intermediate level of care is required for RSS
- a level of care that does not allow an individual to access the type of facility or care they are seeking is considered to be adverse and they have the right to appeal the determination
Frequently Asked Questions
Q: When is PAS required?
A: A PAS/ID is required for all new admissions to Medicaid certified nursing facilities from hospitals or community settings. A new PAS is not needed for individuals being readmitted following a hospital stay or transferring between NFs, with or without an intervening hospital stay. An individual who is discharged from a NF during a hospital stay is not considered a new admission if they return to that NF or are admitted to another NF directly from the hospital.
Q: How long is a PAS/ID valid?
A: The PAS/ID is valid as long as the individual remains in a nursing facility or hospital. If the individual returns to the community, (except for a LOA with a balance of leave days), the PAS becomes invalid.
Q: Does a NF resident ever need a new PAS/ID?
A: PAS/ID is for a new admission, so a NF resident would not need a new PAS/ID but may need a RR/ID (resident review)
Q: When does a NF resident need a RR/ID?
A: There are several situations when a NF resident would require a RR/ID
1. expired convalescent stay – resident is not discharged by day 29 of the convalescent stay
2. significant change in condition – resident who did not previously have indications of serious mental illness (SMI) and/or mental retardation/developmental disability or only had indications of one, now has indications of one or both
3. significant change in condition – resident previously identified as having SMI and/or MR/DD has a change that may impact their treatment or placement options
4. expired timeline for respite stay – resident approved by ODMH and /or ORMRDD for a 14 day respite admission stays beyond day 14
5. expired timeline for emergency admission – resident approved by ODMH and/or ODMRDD for a 7 day emergency admission stays beyond day 7
Q: Who does the RR/ID?
A: The NF completes the RR/ID and determines whether or not the resident has indications of SMI and/or MR/DD. If the resident does not have indications, the screen goes in the medical record with the other PASRR paperwork. If the resident does have indications, the screen along with any supporting documentation is sent to ODMH (fax 614-466-9653, phone 614-466-1063) and/or ODMRDD (fax 614-995-4877, phone 614-728-0183)
Q: What is a convalescent stay?
A: A convalescent stay is a new admission to a NF from a hospital of an individual who entered the hospital from the community and is not anticipated to require long term placement in the NF. The criteria for a convalescent stay are: 1) it is a direct admission to the NF following an in-patient hospital stay, not an admission from the emergency room or observation bed; 2) the individual requires a NF level of services for the condition that was treated in the hospital; 3) the individual’s physician has certified that the stay is anticipated to be for less than 30 days and has signed and dated this certification no later than the date of discharge. If all of these criteria are not met, the individual does not have a valid convalescent stay and needs to undergo PAS.
Q: When is a Level of Care (LOC) needed?
A: A LOC is needed in the following situations: 1) Medicaid is the primary payer for a new admission to a NF, 2) an individual is changing vendor payment from another payer source to Medicaid, 3) an individual transfers to a new NF and Medicaid will be the payer for the new NF, or 4) an individual who had a LOC returns from a hospital stay and does not have a balance of leave days.
Q: How can I submit a request?
A: Requests can be faxed to Preadmission Review. The fax number is 216-621-5994 and the fax machine is available to receive requests 24 hours a day, seven days a week. NFs may mail LOC requests for vendor payment change.
Q: When will my request be processed?
A: Staff is available to process requests Monday through Friday from 8a.m. to 5p.m. Requests from hospitals, emergency requests and NF requests for new admissions or transfers will be processed within 24 hours, if they are complete and correct. NF LOC requests for vendor payment change will be processed within 5 calendar days, if they are complete and correct.
O: Where are the review results sent when the request is completed?
A: The request is returned to the submitter via fax. Please be sure that an accurate fax number is included with your request.
Q: Where should PASRR paperwork be stored?
A: All PASRR paperwork should be maintained in the resident’s current medical record at the NF. If a resident transfers to another NF, the paperwork should be forwarded to the new NF.
Q: What if I need a PAS or LOC when the agency is closed?
A: Extended coverage hours are available for weekends and some holidays. The fax number is 740-245-5977. Coverage is available from 5p.m. Friday until 12a.m. Sunday and until 12a.m. Monday prior to a Monday holiday. Specific holiday coverage varies. Information is faxed or e-mailed to hospitals and NFs prior to each agency holiday.
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