Pre-Admission Review

Preadmission and Level of Care Screenings

The preadmission review process 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 two 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 developmental disabilities. It is required for all admissions to Medicaid-certified Nursing Facilities (NFs), 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 Residential State Supplement (RSS) or Program of All-Inclusive Care for the Elderly (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 an 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 an RR/ID?

A: There are several situations when a NF resident would require an RR/ID, including:

  • Expired convalescent stay – resident is not discharged by day 29 of the convalescent stay
  • Significant change in condition – resident who did not previously have indications of serious mental illness (SMI) and/or developmental disability or only had indications of one, now has indications of one or both
  • Significant change in condition – resident previously identified as having SMI and/or DD has a change that may impact treatment or placement options
  • Expired timeline for respite stay – resident approved by ODMHAS and/or ODODD for a 14-day respite admission stays beyond day 14
  • Expired timeline for emergency admission – resident approved by ODMHAS and/or ODODD 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 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 ODMHAS (fax KEPRO 1-844-285-9764, phone 1-844-723-7816) and/or ODODD (fax 614-995-4877, phone 614-728-0183).

Q: What is a hospital exemption/ODM 07000?

A: A hospital exemption, previously known as 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 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 the 7000 form 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. As of April 1, 2015, all ODM 07000 must be completed electronically in the Hospital Exemption Notification System (HENS).

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. Any individual enrolled in a MyCare Ohio plan does not require a LOC.

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 one business day, if they are complete and correct. NF LOC requests for vendor payment change will be processed within five calendar days, if they are complete and correct.

Q: 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 on weekends and some holidays. Coverage is available from 5 p.m. Friday until 12 a.m. Sunday (Saturday at midnight) and until 12 a.m. Monday (Sunday at midnight) prior to a Monday holiday. The fax number is 419-222-8262. The phone number is 419-222-7723. Callers will be directed to leave a message and calls will be returned. Specific holiday coverage varies. Information is faxed and/or emailed to hospitals and nursing facilities prior to each agency holiday. In addition, coverage information is provided on the agency voicemail message. In the event that there is no coverage or outside of coverage house, requests should be faxed to our agency at 216-621-5994. If it is an emergency request, please indicate that on the cover sheet. COMPLETE requests that do not require further review for serious mental illness or developmental disability can be dated/issued for the date received.

Downloadable Forms

ODJFS Form 3697 Level of Care_Assessment

ODJFS Form 3622 PASARR Identification Screen - via OhioMHAS Site

Hospital Fax Cover Sheet

Nursing Home Fax Cover Sheet

PAR Request for Info

Additional Data Elements Page

 

Contact WRAAA today with any questions you may have.