Pre-Admission Screening Resident Review Presented by EDS Provider Field Consultants October 2009
Agenda • Objectives • Overview • Roles and Responsibilities • Provider Enrollment • Eligibility Process • Billing Procedures • Remittance Advice • Top Denial Reasons • Helpful Checklist • Helpful Tools • Questions PRE-ADMISSION SCREENING RESIDENT REVIEW 2 / October 2009
Objectives At the end of this session, providers will: • Have a better understanding of how the Pre- Admission Screening Resident Review (PASRR) program works • Be able to distinguish the roles and responsibilities of the agencies involved • Know the appropriate forms to use and how to obtain the forms • Understand the PASRR billing process and successfully submit claims PRE-ADMISSION SCREENING RESIDENT REVIEW 3 / October 2009
Overview • Pre-Admission Screening Resident Review (PASRR) – The nursing facility PASRR was federally mandated under the 1987 nursing facility reform – Residents who reside in an IHCP-certified nursing facility (NF) are subject to the PASRR process irrespective of known diagnoses, IHCP enrollment, or method of payment – PASRR is a two-part program: • Pre-Admission Screening (PAS) refers to the assessment and determination of member eligibility, with regard to mental health, for admission to a NF • Resident Review (RR) refers to the evaluation used to determine the necessary services to meet the mental illness (MI) and/or mental retardation and developmentally disabled (MR/DD) condition PRE-ADMISSION SCREENING RESIDENT REVIEW 4 / October 2009
PASRR • PAS Level I – All individuals applying for admission to a nursing facilities, must be given the opportunity to go through the PAS process to determine NF Level of Care (LOC). However, all individuals entering Medicaid-Certified nursing facility must have a PAS completed – The form entitled, Level I Identification Screen, Form 450 B, Section IV must be completed for each applicant by the appropriate entity as stated on the Level I at the time of pre-admission screening • Resident Review Level II(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 diagnosed MR; MR/DD; and/or MI/MR/DD, the assessment is conducted by the Diagnostic and Evaluation (D&E) team PRE-ADMISSION SCREENING RESIDENT REVIEW 5 / October 2009
Area Agency on Aging (AAA) Responsibilities Aging and Disability Resource Centers (ADRCs) • Perform State-required PAS • Ensure that Level I is completed for all Medicaid NF applicants • Determine if Level II review is necessary; when review is needed, notify applicant and refer to appropriate agency: – Community Mental Health Center (CMHC) for MI – Diagnostic and 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 PRE-ADMISSION SCREENING RESIDENT REVIEW 6 / October 2009
Area Agency on Aging (AAA) Responsibilities Aging and Disability Resource Centers (ADRCs) • Issue Form 4 B and send 4 B, Level II evaluation, certification, and related paperwork to NF • A 4 B must be completed even if a person dies or is not admitted • Enter information into the PAS database • PASRR forms may be printed on demand by accessing http: //www. in. gov/icpr PRE-ADMISSION SCREENING RESIDENT REVIEW 7 / October 2009
CMHC Responsibilities • After receiving an AAA referral, the PASRR Level II assessment is conducted by the community mental health centers (CMHCs) for nursing facility residents who have an MI diagnosis or MI episode • CMHC performs Resident Reviews (RRs) as needed and enters the information on the Web, which is sent to the Division of Aging (DA) https: //www. roeing. com/residentr eview • CMHC provides applicable cover letter, final certification, and copy of Level II assessment to the NF PRE-ADMISSION SCREENING RESIDENT REVIEW 8 / October 2009
CMHC Responsibilities • Yearly Resident Review (RR) – Determine – Conduct if yearly RRs are necessary tracking and scheduling of the yearly review – Perform yearly reassessment (if needed) in same calendar quarter • Significant Change RR – Nursing facility initiates a referral to the CMHC Ø Commonly occurs during yearly review or upon observation of a significant change –A significant change indicates the need for a new RR • Missed RR – RR must be completed by the CMHC within 30 calendar days following referral from AAA, the nursing facility, or the EDS Long Term Care Unit PRE-ADMISSION SCREENING RESIDENT REVIEW 9 / October 2009
D&E 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 (RRs) as needed – Complete paperwork and transmit assessment data to State Bureau of Developmental Disabilities Services (BDDS) Unit – BDDS issues the final certification and forwards the AAA to complete the 4 b form • Determine if future Level II yearly assessments are necessary – New D&E teams are only approved to conduct PASRR Level II assessments through contractual arrangements with Division of Disability and Rehabilitative Services (DDRS) PRE-ADMISSION SCREENING RESIDENT REVIEW 10 / October 2009
Nursing Facility Responsibilities • Comply with federal Centers of Medicare & Medicaid Services (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 – Notify the CMHC of any missed RR PRE-ADMISSION SCREENING RESIDENT REVIEW 11 / October 2009
Nursing Facility Responsibilities • Ensure a copy of most recent level II is maintained in the resident’s file • Provide a list of identified MI and MR/DD residents to EDS – A sampling of these residents is included in long-term care audits • Comply with PAS and RR recommendations PRE-ADMISSION SCREENING RESIDENT REVIEW 12 / October 2009
EDS Responsibilities • Enroll providers into the IHCP program • Process PASRR claims • Long Term Care Unit identifies any missed Resident Reviews during the NF audits • Maintain the MI and MR/DD list that is provided by the nursing facility PRE-ADMISSION SCREENING RESIDENT REVIEW 13 / October 2009
Provider Enrollment • Providers who are currently enrolled as IHCP providers do not need to reenroll – Providers will need to complete the IHCP Hospital and Facility Provider Application and Maintenance Form to add the PASRR program • New D&E teams and CMHCs are only approved to conduct PASRR Level II assessments through contractual arrangements with Division of Disability and Rehabilitative Services (DDRS) and Division of Mental Health and Addiction (DMHA) PRE-ADMISSION SCREENING RESIDENT REVIEW 14 / October 2009
Eligibility Process Initial Referrals • The following steps must be completed to ensure the eligibility file for an initial referral is loaded to Indiana. AIM: – AAA must complete a 4 B on all new referrals to the CMHC • Send 4 B to Division of Aging – CMHC must complete an assessment and certification and send to the nursing facility • Nursing facility maintains in resident’s plan of care – AAA enters the certification data into the PAS module – EDS receives the eligibility segment for the member based on the data entered into the PAS module PRE-ADMISSION SCREENING RESIDENT REVIEW 15 / October 2009
Eligibility Process Referrals from the Nursing Facility • The following steps must be completed to ensure the eligibility file for nursing facility referrals is loaded to Indiana. AIM: – Nursing facility initiates referral to the CMHC – CMHC enters data on the Roeing Web site – EDS receives the updated eligibility based on the data entered on the Roeing Web site Note: Please allow two weeks for the eligibility process to be completed PRE-ADMISSION SCREENING RESIDENT REVIEW 16 / October 2009
Billing Procedures • PASRR claims must use the PASRR member’s ID that consists of 800 plus the individual’s Social Security number 800 999 99 9999 (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 member’s Medicaid ID for PASRR claims • Submit PASRR claims via the CMS- 1500 claim form, Web inter. Change, or the 837 P transaction, within one year from the date of service PRE-ADMISSION SCREENING RESIDENT REVIEW 17 / October 2009
Billing Procedures • 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 any missing or invalid information will deny PRE-ADMISSION SCREENING RESIDENT REVIEW 18 / October 2009
Procedure Codes PAS MR/DD Level II • T 2011 U 1 UA – Fee $355. 00 – T 2011: Pre-Admission Screening Resident Review (PASRR) Level II Evaluation, per Evaluation – U 1: PAS (Pre-Admission Screening) – UA: Mental Retardation / Developmental Disability • T 2011 U 1 UA H 1 – Fee $150. 00 (psych exam) – T 2011: Pre-Admission Screening Resident Review (PASRR) Level II Evaluation, per Evaluation – U 1: PAS (Pre-Admission Screening) – UA: Mental Retardation / Developmental Disability – H 1: Integrated Mental Health and Mental Retardation / Developmental Disabilities Program PRE-ADMISSION SCREENING RESIDENT REVIEW 19 / October 2009
Procedure Codes PASRR MR/DD Level II • T 2011 U 2 UA – Fee $355. 00 – T 2011: Pre-Admission Screening Resident Review (PASRR) Level II Evaluation, per Evaluation – U 2: RR (Resident Review) – UA: Mental Retardation / Developmental Disability • T 2011 U 2 UA H 1 – Fee $150. 00 (psych exam) – T 2011: Pre-Admission Screening Resident Review (PASRR) Level II Evaluation, per Evaluation – U 2: RR (Resident Review) – UA: Mental Retardation / Developmental Disability – H 1: Integrated Mental Health and Mental Retardation / Developmental Disabilities Program PRE-ADMISSION SCREENING RESIDENT REVIEW 20 / October 2009
Procedure Codes PAS MI Level II • T 2011 U 1 UB – Fee $322. 00 ( initial) – T 2011: Pre-Admission Screening Resident Review (PASRR) Level II Evaluation, per Evaluation – U 1: PAS (Pre-Admission Screening) – UB: Mental Illness • T 2011 U 1 UB TS – Fee $143. 50 (follow-up) – T 2011: Pre-Admission Screening Resident Review (PASRR) Level II Evaluation, per Evaluation – U 1: PAS (Pre-Admission Screening) – UB: Mental Illness – TS: Follow-up service PRE-ADMISSION SCREENING RESIDENT REVIEW 21 / October 2009
Procedure Codes PASRR MI Level II • T 2011 U 2 UB – Fee $322. 00 – T 2011: Pre-Admission Screening and Resident Review (PASRR) Level II Evaluation, per Evaluation – U 2: RR (Resident Review) – UB: Mental Illness PRE-ADMISSION SCREENING RESIDENT REVIEW 22 / October 2009
Remittance Advice • Providers receive a Remittance Advice (RA) each week if Indiana. AIM has claims in the processing system – RAs are posted at the beginning of each week on Web inter. Change – RA will be posted four consecutive weeks – RA contains the status of each processed claim • RAs list paid claims, denied claims, claims in process, and adjusted claims • The electronic 835 transaction lists paid and denied claims See Chapter 12 of the IHCP Provider Manual for more information about RAs PRE-ADMISSION SCREENING RESIDENT REVIEW 23 / October 2009
Top Denial Reasons PRE-ADMISSION SCREENING RESIDENT REVIEW 24 / October 2009
Edit 4021 Procedure Code Versus Program Indicator • Cause — The procedure code is not covered for the dates of service for the program billed • Resolution — Verify the PASRR procedure codes and modifiers that were submitted on the claim — Verify the eligibility segment dates are within the dates beginning billed PRE-ADMISSION SCREENING RESIDENT REVIEW 25 / October 2009
Edit 2029 NON-IHCP MEMBER INELIGIBLE FOR DATES OF SERVICE • Cause — Member does not have a PASRR eligibility segment for the dates of service billed in the payer processing system • Resolution — Verify the PASRR number that was submitted on the claim — Verify the dates of service that was submitted on the claim are inline with the dates of service submitted on the Roeing website — Verify the AAA has submitted the correct information to Insite PRE-ADMISSION SCREENING RESIDENT REVIEW 26 / October 2009
Edit 4209 No Pricing Segment for Procedure/Modifier Combination • Cause — An invalid procedure code or modifier was used on the claim • Resolution — Verify the PASRR procedure code and modifier are correct for the program billed PRE-ADMISSION SCREENING RESIDENT REVIEW 27 / October 2009
Edit 513 Recipient Name and Number Disagree • Cause — Member name and/or Social Security number is not on file • Resolution — Verify the member’s name and Social Security number PRE-ADMISSION SCREENING RESIDENT REVIEW 28 / October 2009
Edit 2037 Member Not on File for Non-IHCP Program • Cause — Member does not have a PASRR eligibility segment in the payer processing system • Resolution — Verify the PASRR number that was submitted on the claim — Verify that the CMHC has completed the certification online though the Roeing website — Verify the AAA has entered the information into Insite PRE-ADMISSION SCREENING RESIDENT REVIEW 29 / October 2009
Edit 1122 Rendering NPI Must Be Submitted • Cause – Claim was submitted with Legacy Provider Identifier (LPI) only – All healthcare claims must be submitted with a National Provider Identifier (NPI) • Resolution – Include NPI on all healthcare claims PRE-ADMISSION SCREENING RESIDENT REVIEW 30 / October 2009
Helpful Checklist • Applicants do not have to be enrolled Medicaid members for this program • All member IDs must begin with “ 800” followed by the member’s Social Security number • All providers must be enrolled in the PASRR program to submit PASRR claims • Only approved Healthcare Common Procedure Coding System (HCPCS) codes and modifiers will be accepted on claims PRE-ADMISSION SCREENING RESIDENT REVIEW 31 / October 2009
Helpful Checklist • 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 • The 4 B form must be issued by the AAA before the CMHC can submit its claim, which only applies to the PAS process, but not the Resident Review process PRE-ADMISSION SCREENING RESIDENT REVIEW 32 / October 2009
Helpful Tools • IHCP Web site at www. indianamedicaid. com • Customer Assistance – 1 -800 -577 -1278 or (317) 655 -3240 in Indianapolis local area • Written Correspondence – P. O. Box 7263 Indianapolis, IN 46207 -7263 • Provider Relations Field Consultant • Division of Aging – http: //www. in. gov/fssa/2329. htm • Area Agencies on Aging (AAAs) – http: //www. iaaaa. org/members/aaalist. asp • Resident Review on the Web – 1 -888 -787 -5402 – https: //www. roeing. com/residentreview • Contact the INsite Help Desk with problems or questions on the RR-onthe-Web application – E-mail Insite. Help. Desk@fssa. in. gov or call (317) 232 -7858 PRE-ADMISSION SCREENING RESIDENT REVIEW 33 / October 2009
Questions PRE-ADMISSION SCREENING RESIDENT REVIEW 34 / October 2009
Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W 374 Indianapolis, IN 46204 EDS, an HP Company 950 N. Meridian St. , Suite 1150 Indianapolis, IN 46204 EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2009 Hewlett-Packard Development Company, LP. October 2009
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