Free ForwardHealth Reimbursement Request for a PASARR Level I Screen Completion Instructions, F01012A - Wisconsin

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

STATE OF WISCONSIN

FORWARDHEALTH

REIMBURSEMENT REQUEST FOR A PASARR LEVEL I SCREEN COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to authorize and pay for PASARR Level I Screens that meet the ForwardHealth reimbursement guidelines. Nursing facilities (NFs) are required to give full, correct, and truthful information for ForwardHealth reimbursement. This information includes, but is not limited to, the resident's full name, Social Security number (SSN) (HFS 104.02[4], Wis. Admin. Code), and preadmission history. Under s. 49.45(4), Wis. Stats., personally identifiable information about NF residents is confidential and is used for purposes directly related to the processing of requests for reimbursement. Failure to supply all the information requested on this form will result in a denial of the reimbursement request. The information on this reimbursement request is needed to ensure that Medicaid-certified long term care facilities, nursing facilities, 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 1 admission are reimbursable. 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 1 Screen for a readmission or interfacility transfer, the NF should not seek reimbursement for it. Providers may submit completed reimbursement requests by mail to the following address: ForwardHealth 6406 Bridge Rd Madison WI 53784-0002 ForwardHealth will not supply NFs with a bulk supply of this form. Nursing facilities may make multiple copies of this form or obtain additional copies from the ForwardHealth Portal at www.forwardhealth.wi.gov/.
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INSTRUCTIONS Name -- NF Enter the actual name of the NF, not the corporate name. POP ID Enter the three-digit number assigned to the NF by the Division of Long Term Care. This number never changes, even with a change of ownership. This number may be found on the NF's ForwardHealth Rate Letter. Contact the NF's Regional ForwardHealth Auditor if assistance is required in obtaining this number. National Provider Identifier -- NF Enter the National Provider Identifier assigned to the NF. Contact the NF's billing department or administrator to obtain this number. Last Name -- Resident Enter the resident's last name. First Name -- Resident Enter the resident's first name. Social Security Number -- Resident Enter the resident's SSN. Requests for reimbursement cannot be processed without the resident's SSN. Screen Date Enter the date the Level I Screen is completed in MM/DD/CCYY format. The date entered must either be identical to or prior to the date 1 entered as the Admission Date on this request. The Level I Screen should meet the definition of a new admission screen. ForwardHealth must receive the request for reimbursement within 365 days of the screen date. Admission Date Enter the date the resident was admitted to the NF in MM/DD/CCYY format. This date must correspond with the Screen Date.

REIMBURSEMENT REQUEST FOR A PASARR LEVEL I SCREEN COMPLETION INSTRUCTIONS F-1012A (10/08)

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Preadmission History Enter an "X" to indicate where the resident was located prior to admission to the NF. Mark only one box. If this section is not completed, is marked with multiple responses, or if the response indicates that this is not a preadmission screen, the result will be a denial of the reimbursement request. Telephone Number -- Provider Enter the telephone number ForwardHealth should use if there is a need to contact the NF regarding this reimbursement request. Signature and Date Signed -- Provider An authorized representative of the NF must read the certification statement and sign and date this form. If either the signature or the date is omitted, the result will be a denial of the reimbursement request.

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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 1 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.