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

abuse and controlled drugs as identified by Federal regulations. The nursing facility may alsouse single unit package drug distribution systems in which the quantity stored is minimal and amissing dose can be readily detected.The administrator or designee must establish a policy to assure residents’ requests for obtainingprescription medications from sources other than the contracted pharmacy will be honored.Prescription drugs are covered for residents of nursing facilities when prescribed by a qualifiedpractitioner and furnished by a Medicaid participating pharmacy. The coverage rules andregulations may be found in Chapter 518 Pharmacy Services.Residents are exempt from all co-pay requirements. Non-covered drugs are not reimbursed byMedicaid for residents of nursing facilities.514.7.3 Rehabilitation ServicesIf specialized rehabilitative services such as, but not limited to, physical therapy, speechlanguagepathology, occupational therapy, respiratory therapy and psychological or psychiatricrehabilitative services, are required in the resident’s comprehensive plan of care, theadministrator or designee must provide the required services directly or in accordance with 42CFR 483.45 and §514. 8.2 of this manual. These services are covered services included in thereimbursement from Medicaid.514.7.4 Minimum Data Set (MDS)The Minimum Data Set (MDS), Version 3.0 with the RUGs III and the West Virginia-specificSection S are to be used by NFs to fulfill the federally mandated requirements for payment.These forms may be found in the Resident Assessment Instrument (RAI) Manual as publishedand periodically updated by CMS; please refer to OHFLAC website for Section S instructionswww.wvdhhr.org/ohflac specifications.CMS requires that a comprehensive MDS assessment be completed on every resident admittedinto a NF by day 14 of the admission and reassessed on at least a quarterly basis and annuallythereafter. Reference should be made to the RAI manual for the complete Omnibus BudgetReconciliation Act (OBRA) assessment schedule.514.7.5 MDS Submission Criteria for ReimbursementBMS utilizes the MDS assessments to determine (through the West Virginia specific 29 – casemix grouper), the acuity level of each individual residing in the nursing facility. West Virginia hascase mix classes 01-29, (when billed on the UB claim form or 837I format, the scores aredepicted as AAA01-AAA29). The case mix workbook may be found online atwww.dhhr.wv.gov/bms. The billing schedule is published annually, which may also be found onthe BMS website at www.dhhr.wv.gov/bms, with the nursing facility billing deadline dates, aswell as the MDS extraction date.Department of Health and Human Resources Chapter 514: Nursing Facility Services Page 36January 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.