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

individual has not been a member of Medicaid upon admission to the nursing facility, a newPAS will need to be completed before the Medicare benefit has ended and the AdvancedBeneficiary Notice of Medicare Non-Coverage has been issued. This ensures proper placementif circumstances warrant long-term placement for the individual in the nursing facility afterMedicaid becomes the primary payer.A new medical assessment must be completed for Medicaid Medical Eligibility for the nursingfacility resident for all of the following situations:Application for the Medicaid nursing facility benefit;Resident transfers from one nursing facility to another nursing facility, even if the transferis within the same corporation;Resident returns to the same nursing facility from any healthcare setting other than anacute care hospital;Resident transfers to an acute care hospital, then to a hospital-based skilled nursing unit,and then returns to the original nursing facility;Resident converts from private pay or any other payer to Medicaid; orExpiration of the Current PAS due to time limitation.514.6.4 Physician CertificationA physician who has knowledge of the individual must certify the need for nursing facility care.Medical eligibility for persons in need of nursing facility services is determined initially from theinformation supplied by the physician on the specified assessment tool. The information mustbe current as to the individual’s need for nursing facility care. With the physician’s signatureand date, this is considered the certification for nursing facility services.514.6.5 Medical Necessity (Level I)All individuals admitted or requesting admission to a Medicaid certified nursing facility must bescreened for the possible presence of a major mental illness, and/or anintellectual/developmental disability (MI/I/DD). This review is identified as the Level I evaluation.Any individual identified with the possible presence of mental health issues must be furtherevaluated.514.6.6 Pre-Admission Screening and Resident Review (PASRR) (Level II)If the Level I evaluation found the possible presence of MI and/or I/DD, further evaluation of theindividual must be completed to obtain a definitive diagnosis and the need for specializedservices for the mental health condition. This evaluation is identified as a Level II evaluationand must be completed by an individual identified by the BMS as an approved Level IIDepartment of Health and Human Resources Chapter 514: Nursing Facility Services Page 31January 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.