Free ForwardHealth Nurses Aide Training and Competency Test Reimbursement Request Completion Instructions, F01013A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1013A (10/08)

STATE OF WISCONSIN

FORWARDHEALTH

NURSES AIDE TRAINING AND COMPETENCY TEST REIMBURSEMENT REQUEST COMPLETION INSTRUCTIONS
The information on this reimbursement request is required to enable ForwardHealth to reimburse Medicaid-certified long term care nursing facilities (NFs) for certified nursing assistant (CNA) training and/or testing. This reimbursement is only available for a CNA who is employed by the NF. Nursing facilities are required to give full, correct, and truthful information for ForwardHealth reimbursement. This information includes, but is not limited to, the CNA's name, Social Security number (SSN), and date of hire. Under s. 49.45(4), Wis. Stats., personally identifiable information is confidential and is used for purposes directly related to ForwardHealth administration such as processing provider requests for reimbursement. Failure to supply all the information requested on this form will result in a denial of the reimbursement request. Reference the Wisconsin Nurse Aide Registry Web site at www.forwardhealth.wi.gov prior to submitting this reimbursement request to obtain/verify certification information. Do a "Search by SSN" to verify the CNA's SSN and his or her competency test date. Inclusion date is the competency test date for newly certified CNAs. A reimbursement request will deny if either the SSN or the competency test date do not match what is on the Wisconsin Nurse Aide Registry. Per 42 CFR Part 431 and s. 483.152(c), NFs are eligible to seek reimbursement when they have incurred testing and/or training costs for an employee or when they have hired a CNA who incurred testing and/or training costs within 365 days of their employment by the NF. ForwardHealth has established a maximum amount that CNAs have to be reimbursed. Nursing facilities receive a percentage of that maximum amount based on their ForwardHealth utilization, number of ForwardHealth patient days divided by their total patient days. ForwardHealth implemented this reimbursement methodology on October 1, 1997. It ensures that CNA training and testing costs are properly allocated between ForwardHealth, Medicare, and private pay residents. 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/. 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 (DLTC). 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 -- CNA Enter the CNA's last name. First Name -- CNA Enter the CNA's first name. SSN -- CNA Enter the CNA's SSN. Prior to submitting this request to ForwardHealth, access the Wisconsin Nurse Aide Registry and verify that the SSN entered in this element is the SSN on file for this CNA. If the SSN entered in this element does not match the SSN on the Registry, the request will be denied. Registration Number -- CNA Enter the CNA's six-digit registration number. This number is available on the Wisconsin Nurse Aide Registry Web site. It may be obtained by entering either the CNA's name or SSN.

NURSES AIDE TRAINING AND COMPETENCY TEST REIMBURSEMENT REQUEST COMPLETION INSTRUCTIONS F-1013A (10/08)

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Date of Hire Enter the date the CNA was hired by the NF in MM/DD/CCYY format. If the CNA was hired prior to obtaining his or her CNA certification, enter that initial hire date in this element. If this element is not completed, the request will be denied. Training Completion Date Enter the date the CNA completed the required classroom/clinical hours in MM/DD/CCYY format. If the training occurred in Wisconsin, enter the date that appears on the CNA's training certificate. Competency Test Date Enter the date the CNA passed the written/skills examination in MM/DD/CCYY format. For newly certified CNAs, the Inclusion Date and Competency Test Date are the same. If a CNA is required to retest to renew his or her certification, the "Employment Eligibility Expiration Date" will be updated to reflect a date that is exactly two years (or 730 days) past the recertification test date. Inclusion Date Enter the date the CNA was initially added to the Wisconsin Nurse Aide Registry in MM/DD/CCYY format. This date is available on the Wisconsin Nurse Aide Registry Web site. It may be obtained by entering either the CNA's name or SSN. This date is never updated. Training and Testing Questions For questions 1-3, check the box for the applicable answer. Name and Telephone Number -- NF Contact Enter the name and telephone number of the person at the NF whom the DLTC should contact regarding questions about this reimbursement request. This element only needs to be completed if the NF Contact is a person other than the authorized representative signing this form. 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, it will result in a denial of the request.