Chapter 514 - Nursing Facility Services - DHHR - State of West ...

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The financial application for nursing facility services is made to the local WV DHHRoffice.The medical eligibility determination is based on a physician’s assessment of themedical and physical needs of the individual. At the time of application the prospectiveresident should be informed of the option of receive home and community based longterm.The PAS assessment must have a physician signature dated not more than 60days prior to admission to the nursing facility.514.6.2 Pre-Admission Screening and Resident Review (PAS)Pre-admission screening for medical necessity of nursing facility services is a two-step process.The first step (Level I) identifies the medical need for nursing facility services based onevaluation of identified deficits and screens for the possible presence of a major mental illness,mental retardation, and/or developmental disability. The second step (Level II) identifies if theindividual needs specialized services for a major mental illness, mental retardation, and/ordevelopmental disability.514.6.3 Medical Eligibility Regarding the Pre-Admission ScreeningTo qualify medically for the nursing facility Medicaid benefit, an individual must need directnursing care 24 hours a day, 7 days a week. BMS has designated a tool known as the Pre-Admission Screening form (PAS) (see appendix II) to be utilized for physician certification of themedical needs of individuals applying for the Medicaid benefit.An individual must have a minimum of five deficits identified on the PAS. These deficits will bedetermined based on the review by BMS/designee in order to qualify for the Medicaid nursingfacility benefit.These deficits may be any of the following: #24: Decubitus – Stage 3 or 4 #25: In the event of an emergency, the individual is c) mentally unable or d) physicallyunable to vacate a building. a) and b) are not considered deficits. #26: Functional abilities of the individual in the home.Eating: Level 2 or higher (physical assistance to get nourishment, not preparation)Bathing: Level 2 or higher (physical assistance or more)Grooming: Level 2 or higher (physical assistance or more)Dressing: Level 2 or higher (physical assistance or more)Continence: Level 3 or higher (must be incontinent)Orientation: Level 3 or higher (totally disoriented, comatose)Transfer: Level 3 or higher (one person or two persons assist in the home)Walking: Level 3 or higher (one person assist in the home)Wheeling: Level 3 or higher (must be Level 3 or 4 on walking in the home to use, Level 3or 4 for wheeling in the home.) Do not count outside the home.Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 29January 1, 2013DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures,and must be supplemented with all State and Federal Laws and Regulations.
#27: Individual has skilled needs in one these areas – (g) suctioning, (h) tracheostomy, (i)ventilator, (k) parenteral fluids, (l) sterile dressings, or (m) irrigations.#28: Individual is not capable of administering his/her own medications.This assessment tool must be completed, signed and dated by a physician. The physician’ssignature indicates “to the best of my knowledge, the patient’s medical and related needs areessentially as indicated”. It is then forwarded to the Bureau or their designee for medicalnecessity review. The assessment tool must be completed and reviewed for every individualresiding in a nursing facility, regardless of the payment source for services.PAS’ may be submitted to the Bureau’s Utilization Management Contractor electronicallythrough a secure website. The faxing option will still be available and is entered into the directdata entry (DDE) by the UMC. When a PAS is submitted electronically, the physician has twooptions for providing attestation that the patient’s medical and related needs are accurate asindicated with their signature.1. If the physician has the capability for electronic signature (an actual version of theirsignature, such as when one signs for a credit card or package, the signature iscreated electronically), not just a typed version of their name; OR,2. #39 will be checked on the PAS which certifies Dr. Jane Doe has completed thisPAS (his or her name will be typed out). Then the PAS MUST be printed off and thephysician’s physical signature (such as the signature you see when one signs aletter) must be added. The signed page is attached to the electronic record and/orsent to the nursing facility accepting the resident.On either option for signature, the date is automatically populated and that will be the date forthe start of Medicaid reimbursement for services, if the individual meets financial eligibility forthe nursing facility benefit. However, the PAS must be signed either electronically or physicallyby the physician in order for the PAS to be valid.If an actual written signature either from the resident or responsible party cannot be obtained,verbal consent is necessary. The individuals obtaining verbal consent must sign/date along withthe witness who also signs/dates. However, the entity completing the PAS MUST obtain anactual signature from the resident or responsible party on the hard copy of the PAS which willbe the PAS on file with the nursing facility and available for review upon request.Each nursing facility must have a signed, original pre-admission screening tool to qualify theindividual for Medicaid benefits and to meet the Federal PASRR requirements. Should thereceiving nursing facility fail to obtain an approved assessment with an original signature fromthe resident or responsible party prior to admission of a Medicaid eligible individual, theMedicaid program cannot pay for services rendered at the nursing facility for that individual.The individual cannot be charged for the cost of care during the non-covered period.A Medicaid member, who had Medicare and reaches the 21st day of Medicare Coverage andwill be converting to Medicare Part A coverage with Medicaid as the co-pay, does not need anew PAS as long as the facility has a current PAS that is no more than 60 days old. If theDepartment of Health and Human Resources Chapter 514: Nursing Facility Services Page 30January 1, 2013DISCLAIMER: This manual does not address all the complexities of Medicaid policies and procedures,and must be supplemented with all State and Federal Laws and Regulations.
Page 1 and 2: CHAPTER 514 - COVERED SERVICES, LIM
Page 3 and 4: 514.4.11 Services Provided by Outsi
Page 5 and 6: 514.10.4 Podiatry Services ........
Page 7 and 8: 514.13.47 Field Audit .............
Page 9 and 10: in the balance as part of the proce
Page 11 and 12: Minimum Data Set (MDS) - a core set
Page 13 and 14: eimbursement and annually thereafte
Page 15 and 16: A change in ownership of a nursing
Page 17 and 18: The Commissioner, in his or her dis
Page 19 and 20: 514.3.2 Civil Money Penalty (CMP)A
Page 21 and 22: Employment of an individual with on
Page 23 and 24: 514.4.7 Administrative PoliciesThe
Page 25 and 26: The agreement / contract must clear
Page 27 and 28: Where residents are in a nursing fa
Page 29: 514.5.10 Food and Dietary DirectorI
Page 33 and 34: evaluator. All Level II evaluators
Page 35 and 36: It is the responsibility of the nur
Page 37 and 38: abuse and controlled drugs as ident
Page 39 and 40: 514.8.1 Nursing ServicesCovered ser
Page 41 and 42: Upon transfer to another nursing fa
Page 43 and 44: 514.9.2 Transfer and Discharge Poli
Page 45 and 46: the resident’s physical condition
Page 47 and 48: 514.9.10 Conveyance Upon DischargeU
Page 49 and 50: 514.10.6 Emergency Ambulance Transp
Page 51 and 52: 514.10.8 Documentation Requirements
Page 53 and 54: certification must include document
Page 55 and 56: It is not mandatory for providers t
Page 57 and 58: ownership and control has occurred
Page 59 and 60: The standard hours PPD, by bed grou
Page 61 and 62: The Model Nursing Facility Standard
Page 63 and 64: Starting with its total costs, incl
Page 65 and 66: eimbursable. For example: if a faci
Page 67 and 68: 514.13.37 Cost AdjustmentReported f
Page 69 and 70: If it has been determined that a fa
Page 71 and 72: CHAPTER 514NURSING FACILITY SERVICE
Page 73 and 74: Changes in Ownership, either in par
Page 75 and 76: CHAPTER 514NURSING FACILITY SERVICE
Page 77 and 78: II. MEDICAL ASSESSMENTDate ________
Page 79 and 80: III. MI/MR ASSESSMENTDATE: ________
Page 81 and 82:
V. ELIGIBILITY DETERMINATION DATE:
Page 83 and 84:
West Virginia Department of Health
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