Pre-Admission Screening Resident Review (PASRR)

Transcription

1 Pre-Admission Screening Resident Review (PASRR) Presented by EDS Provider Field Consultants 1 / October 2007 / EDS INTERNAL

2 Agenda Objectives Overview Roles and Responsibility Billing Procedures Web Interchange Remittance Advice Billing Codes Top Denials Claim Submission Checklist Helpful Tools Questions 2 / October 2007 / EDS INTERNAL

3 OBJECTIVES At the end of this session, providers will: Know how the PASRR program works Know the roles and responsibilities of the different agencies involved Know what forms to use and how to obtain the forms Know how to bill PASRR claims 3 / October 2007 / EDS INTERNAL

4 Overview Pre-Admission Screening and Resident Review (PASRR) The nursing facility PASRR was federally mandated under the 1987 nursing facility reform. Residents, regardless of known diagnoses or methods of payment, IHCP or non-ihcp, who reside in an IHCP-certified Nursing Facility (NF) are subject to the PASRR process. PASRR is a two-part program. Pre-Admission Screening (PAS) refers to the assessment and determination of member eligibility for admission to a NF. Resident Review (RR) refers to the evaluation used to determine the necessary services to meet the MI and/or MRDD condition. 4 / October 2007 / EDS INTERNAL

5 PASRR PAS All individuals applying for admission to Medicaid certified nursing facilities, must be pre-screened through the PAS process to determine NF Level of Care (LOC). The Level I Identification Screen, Form 450B, Section IV, must be completed for each applicant by the appropriate entity as stated on the Level I at the time of preadmission screening. Resident Reviews (RR) An assessment will be conducted by the Community Mental Health Centers (CMHCs) for nursing facility residents who may be MI. For those individuals who are MI and MRDD the assessment is conducted by the Diagnostic and Evaluation (D&E) Team. 5 / October 2007 / EDS INTERNAL

6 Area Agency of Aging (AAA) Responsibilities Perform state required Pre-Admission Screening (PAS) Assure that Level I is completed for all Medicaid NF applicants Determine if Level II review is necessary and, when review is needed, notify applicant and refer to appropriate agency: Community Mental Health Center (CMHC) for MI Diagnostic & Evaluation (D&E) Team for MR/DD or MI/MR/DD Review evaluation information and determine if the NF applicant is: Appropriate for NF admission In need of specialized services. Issue Form 4B and send 4B, Level II evaluation, certification, and related paperwork to NF. Enter information into the PAS database. 6 / October 2007 / EDS INTERNAL

7 CMHC Responsibilities After receiving a AAA referral, the PASRR Level II assessment is conducted by the Community Mental Health Centers (CMHCs) for nursing facility residents who have a MI diagnosis or a MI episode The CMHC performs Resident Reviews (RR) as needed and enters the information on the Web which is sent to the Division of Aging (DA) The CMHC provides to the NF with applicable cover letter, final certification, and copy of Level II assessment 7 / October 2007 / EDS INTERNAL

8 CMHC Responsibilities (Continued) Yearly RR Determine if yearly RR s are necessary Tracking and scheduling Yearly reassessment (if needed) in same calendar quarter Significant Change RR A significant change indicates the need for a new RR Missed RR Same as significant change process except for time frames; Level II must be completed within 30 calendar days following referral 8 / October 2007 / EDS INTERNAL

9 Diagnostic and Evaluation Team Responsibilities A PASRR Level II assessment is conducted by the Diagnostic and Evaluation (D&E) Team for nursing facility residents who may be MI and MR/DD Perform Resident Reviews (RR) as needed Complete paperwork and transmit assessment data to State Bureau of Developmental Disabilities Services (BDDS) Unit Provide NF with cover letter, final certification, and copy of Level II assessment Determine if future Level II yearly assessments is necessary New D&E Teams are only approved to conduct PASRR Level II assessments through contractual arrangements with Division of Disability, Rehabilitative Services (DDRS) 9 / October 2007 / EDS INTERNAL

10 Nursing Facility Responsibilities Comply with Federal CMS and PASRR requirements Ensure a Level I assessment was completed and is maintained in every resident file Develop and implement new plan of care Based on the above activities, determine if new Level II review is needed Notify CMHC or BDDS in writing if new review is needed Promptly notify CMHC or BDDS if previously identified MI or MR/DD resident has been admitted, discharged or transferred 10 / October 2007 / EDS INTERNAL

11 Nursing Facility Responsibilities cont. Ensure a copy of most recent level II is maintained in the residents file Provide list of identified MI and MR/DD residents to EDS Comply with PAS and RR recommendations 11 / October 2007 / EDS INTERNAL

12 EDS Responsibilities Enroll providers into the IHCP program Process PASRR claims MDS Audit Unit identifies any missed Resident Reviews during the NF audits Maintains the MI and MR/DD list that is provided by the nursing facility 12 / October 2007 / EDS INTERNAL

13 Provider Enrollment Provider Enrollment: Providers who are currently enrolled as IHCP providers do not need to re-enroll Providers will need to complete an update provider enrollment form to add the PASRR program as a specialty New D&E Teams and CMHCs are only approved to conduct PASRR Level II assessments through contractual arrangements with Division of Disability, Rehabilitative Services (DDRS) and Division of Mental Health and Addiction (DMHA) 13 / October 2007 / EDS INTERNAL

14 Ordering Forms Forms can be ordered online at When placing an order for PASRR forms, the full title name, State form number, and the revision date should be specified for example: PASRR Level I Identification Evaluation Criteria State Form (R2/7-02)/Form 450B/ PASRR2A-Sections IV and V, Part A Order forms from the Forms Distribution Center by writing to the following address: Department of Administration Forms Distribution Center 6400 East 30th Street Indianapolis, IN / October 2007 / EDS INTERNAL

15 15 / October 2007 / EDS INTERNAL

16 Billing Procedures PASRR claims must use the PASRR member s ID that consists of 800 plus the individual s Social Security Number (800 + Social Security number) If the resident is a Medicaid member the PASRR ID number will still remain 800 plus the Social Security number Do not use the members Medicaid ID for PASRR claims Submit PASRR claims via the CMS-1500 claim form, Web interchange, or the 837P transaction, within one year from the date of service. 16 / October 2007 / EDS INTERNAL

17 Procedure Codes PAS MR/DD Level I T2011 U1 UA Fee $ T2011: Preadmission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation U1: PAS (Preadmission Screening) UA: Mental Retardation / Developmental Disability T2011 U1 UA H1 Fee $ T2011: Preadmission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation U1: PAS (Preadmission Screening) UA: Mental Retardation / Developmental Disability H1: Integrated Mental Health and Mental Retardation / Developmental Disabilities Program 17 / October 2007 / EDS INTERNAL

18 Procedure Codes PASRR MR/DD Level II T2011 U2 UA Fee $ T2011: Preadmission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation U2: RR (Resident Review) UA: Mental Retardation / Developmental Disability T2011 U2 UA H1 Fee $ T2011: Preadmission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation U2: RR (Resident Review) UA: Mental Retardation / Developmental Disability H1: Integrated Mental Health and Mental Retardation / Developmental Disabilities Program 18 / October 2007 / EDS INTERNAL

19 Procedure codes PAS MI Level I T2011 U1 UB Fee $ T2011: Preadmission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation U1: PAS (Preadmission Screening) UB: Mental Illness T2011 U1 UB TS Fee $ T2011: Preadmission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation U1: PAS (Preadmission Screening) UB: Mental Illness TS: Follow-up service 19 / October 2007 / EDS INTERNAL

20 Procedure Codes PASRR MI Level II T2011 U2 UB Fee $ T2011: Preadmission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation U2: RR (Resident Review) UB: Mental Illness 20 / October 2007 / EDS INTERNAL

21 Billing Procedure Cont. The maximum fee, procedure code, and all modifiers must be billed on the claim PASRR services cannot be combined with a claim for any other Medicaid services Claims that encounter an edit or an audit for missing or invalid information will no longer suspend 21 / October 2007 / EDS INTERNAL

22 Remittance Advice (RA) Providers receive a remittance advice (RA) each week if IndianaAIM has claims in the processing system. The IHCP mails paper RAs to providers each Tuesday. The RA contains the status of each processed claim. The electronic 835 transaction lists paid and denied claims. Paper RAs list paid claims, denied claims, claims in process, and adjusted claims. The paper RA also includes claim correction forms (CCFs). See Chapter 12 of the IHCP Provider Manual for more information about RAs. 22 / October 2007 / EDS INTERNAL

23 Top Denial Reasons 1010 Rendering provider not an eligible member of the group, or the billing provider is equal to the rendering provider 4021 Procedure code vs program indicator 2037 member not on file for non-ihcp program 251 First modifier invalid 531 Recipient name and number disagree 1001 Billing provider not enrolled at the service location for the program billed 23 / October 2007 / EDS INTERNAL

24 EDS Web interchange Overview Web interchange is a free Web application that allows providers to submit PASRR claims electronically, review claims already submitted, and verify eligibility status of the member. Web interchange is HIPAA-compliant. Member and claim information is protected by Encryption and secure socket layer (SSL) technology Web interchange requires Microsoft Internet Explorer 6.0 and above. 24 / October 2007 / EDS INTERNAL

25 EDS Web interchange Features Check Inquiry Allows providers to inquire about previously received payments. Payment inquiries are made based on the check or electronic funds transfer (EFT) number or date range. Providers may click on the displayed check or EFT number to identify the claims paid on that specific check or EFT. Void A void is a deletion of a paid claim. Replacement The replacement is a corrected claim. The replace this claim function may be used to correct an incorrect payment. 25 / October 2007 / EDS INTERNAL

26 EDS Web interchange How to Enroll To use Web interchange, providers must designate at least one person to be the Web Administrator. The Web Administrator must complete the Administrator Request Form available at and mail it to the address shown on the form. Direct questions about accessing Web interchange to the EDS Electronic Solutions Helpdesk at (317) in the Indianapolis area or , or by at 26 / October 2007 / EDS INTERNAL

27 Helpful Check List All member ID s must begin with 800 followed by the members Social Security number All providers must be enrolled in the PASRR program to submit PASRR claims Only approved HCPCS codes and Modifiers will be accepted on claims A PAS level I must be completed on all members entering a Medicaid enrolled nursing facility A Level II must be completed on residents who are suspected of having a severe mental illness or developmental disability A Form 4B must be issued by the AAA before the CMHC can submit their claim, which only applies to the PAS process, but not the Resident Review process Applicants do not have to be Medicaid members for this program 27 / October 2007 / EDS INTERNAL

28 Helpful Tools IHCP Web site at IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance , or in the Indianapolis local area Written Correspondence P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant Resident Review on the Web Contact the INsite Help Desk with problems or questions on the RR-on-the-web application. or call / October 2007 / EDS INTERNAL

29 Questions 29 / October 2007 / EDS INTERNAL

30 Presentation by EDS Provider Field Consultants EDS 950 N. Meridian St., Suite 1150 Indianapolis, IN EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people Electronic Data Systems Corporation. All rights reserved. 30 / October 2007 / EDS INTERNAL