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The preadmission review process applies to most individuals seeking access to Medicaid-funded, long-term care. The purpose is to ensure that individuals receive the care they need in the most appropriate, least restrictive setting. A preadmission review includes two major components: preadmission screening (PAS) and level of care (LOC). One or both parts can be required.
PAS – Is the process for screening individuals for indications of serious mental illness and/or developmental disabilities. It is required for all admissions to Medicaid-certified Nursing Facilities (NFs), regardless of the payment source. This is a federal mandate. All PAS requirements must be met before a level of care determination can be made for an individual seeking Medicaid as their primary payment source.
LOC – Is a designation of an individual’s functional and nursing needs pursuant to the requirements and criteria in the Ohio Administrative Code (OAC) rules.
A: A PAS/ID is required for all new admissions to Medicaid-certified nursing facilities from hospitals or community settings. A new PAS is not needed for individuals being readmitted following a hospital stay or transferring between NFs, with or without an intervening hospital stay. An individual who is discharged from a NF during a hospital stay is not considered a new admission if they return to that NF or are admitted to another NF directly from the hospital. All PAS/ID must be completed in the Healthcare Electronic Notification System (HENS).
A: The PAS/ID is valid if the individual remains in a nursing facility or hospital. If the individual returns to the community, (except for a LOA with a balance of leave days), the PAS becomes invalid.
A: PAS/ID is for a new admission, so a NF resident would not need a new PAS/ID but may need a Resident Review (RR/ID).
A: There are several situations when a NF resident would require an RR/ID, including:
A: The NF completes the RR/ID and it is determined whether or not the resident has indications of SMI and/or DD. If the resident does not have indications, the screen goes in the medical record with the other PASRR paperwork. If the resident does have indications, the screen, along with any supporting documentation, is sent to Ascend (fax 1-877-431-9568, phone 1-833-917-2777 or 1-877-431-1388) and/or ODODD (fax 614-995-4877, phone 614-728-9509) via HENS.
A: A hospital exemption, previously known as a convalescent stay, is a new admission to a NF from a hospital of an individual who entered the hospital from the community and is not anticipated to require long term placement in the NF. The criteria are: 1) it is a direct admission to the NF following an in-patient hospital stay, not an admission from the emergency room or observation bed; 2) the individual requires a NF level of services for the condition that was treated in the hospital; 3) the individual’s physician has certified that the stay is anticipated to be for less than 30 days and has signed and dated the 7000 form no later than the date of discharge; 4) not in a psychiatric unit; and 5) has not had an adverse determination within the past 60 days. If all of these criteria are not met, the individual does not have a valid convalescent stay and needs to undergo PAS. All ODM 07000 must be completed electronically in the HENS system.
A: A LOC is needed in the following situations: 1) Medicaid is the primary payer for a new admission to a NF, 2) an individual is changing vendor payment from another payer source to Medicaid, 3) an individual transfers to a new NF and Medicaid will be the payer for the new NF, or 4) an individual who had a LOC returns from a hospital stay and does not have a balance of leave days. Any individual enrolled in a MyCare Ohio plan or who is on hospice does not require a LOC.
A: All 07000, PAS/ID and RR/ID must be completed in HENS, administered by OH Dept of Aging (ODA). LOC requests can be faxed to WRAAA Preadmission Review dept 24 hours a day, seven days a week via fax number 216-621-5994. LOC requests can also be submitted to WRAAA via email to: firstname.lastname@example.org.
A: Staff is available to process requests Monday through Friday from 8 a.m. to 5 p.m. Requests from hospitals, emergency requests, and NF requests for new admissions will be processed within one business day. NF LOC requests for payer change and transfer to a different NF will be processed within five calendar days.
A: The request is returned to the submitter via fax or encrypted email. Please be sure that an accurate fax number or email address is included with your request.
A: All PASRR paperwork should be maintained in the resident’s current medical record at the NF. If a resident transfers to another NF, the paperwork should be forwarded to the new NF as part of the legal record.
A: Extended coverage hours are available on weekends and some holidays. Coverage is available from 4:30 p.m. Friday until 12 a.m. Sunday (Saturday at midnight) and until 12 a.m. Monday (Sunday at midnight) prior to a Monday holiday. The fax number is 419-222-8262. The phone number is 419-222-7723. Callers will be directed to leave a message and calls will be returned. Specific holiday coverage varies. Information is faxed and/or emailed to hospitals and nursing facilities prior to each agency holiday. In addition, coverage information is provided on the agency voicemail message. In the event that there is no coverage or outside of coverage hours, requests should be faxed or emailed to WRAAA. If it is an emergency request, please indicate that on the cover sheet.