Free ForwardHealth Reimbursement Request for a PASARR Level I Scren, F01012 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1012 (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

REIMBURSEMENT REQUEST FOR A PASARR LEVEL I SCREEN
The information on this reimbursement request is required to ensure that Medicaid-certified long term care facilities, nursing facilities (NFs), are only paid for Level l Screens that are required under 42 CFR s. 483.104. On February 1, 1997, new reimbursement guidelines were implemented by ForwardHealth based on this federal regulation. Effective February 1, 1997, only Level l Screens that result in a new admission1 are reimbursable.
2 Nursing facilities are not required to perform a new Level l Screen on residents who are returning from a hospital stay, readmission , or 3 interfacility transfer . If an NF elects to perform a new Level I Screen for a readmission or interfacility transfer, the NF should not seek reimbursement for it.

Providers may submit this completed form by mail to ForwardHealth, 6406 Bridge Road, Madison, WI 53784-0002. Instructions: Type or print clearly. Before completing this form, read the Reimbursement Request for a PASARR Level I Screen Completion Instructions, F-1012A. Name -- NF (Physical Name, not Corporate Name) POP ID National Provider Identifier -- NF

Last Name -- Resident

First Name -- Resident

Social Security Number -- Resident

Screen Date

Admission Date

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A. B.

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A private residence. Another Medicaid-certified NF.

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Preadmission History -- Where was this resident prior to his or her admission to this NF? Check only one box. Multiple responses will result in a denial of the reimbursement request.

C. Hospital -- admitted to the hospital from a private residence. D. Hospital -- readmission2.

E. Hospital -- interfacility transfer3. CERTIFICATION This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this reimbursement request is from federal and state funds, and that any false claims, statements, documents, or concealment of material fact may be prosecuted under applicable federal or state laws. Telephone Number -- Provider

SIGNATURE -- Provider

Date Signed -- Provider

1

2

3

New Admission -- An individual is admitted to an NF from a private residence (e.g., private home, group home, or intermediate care facility-mentally retarded [ICF-MR]) with or without an intervening hospital stay. If an individual transfers to an NF from a hospital, and his or her residence prior to the hospital stay was a private residence, a Level I Screen is required. Readmission -- An individual is readmitted to an NF from a hospital to which he or she was transferred for the purpose of receiving care. If the transferring NF considered the resident discharged from the NF during the time he or she was in the hospital, it is still considered a readmission when that resident transfers back to the NF from the hospital. A new Level I Screen is not required. If the resident was discharged to his or her private residence from the hospital and needs to return to the NF at a later time, it is considered a new admission. Interfacility Transfer -- An individual is transferred from one NF to another NF, with or without an intervening hospital stay. The admitting NF is not required to perform a new Level I Screen.

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