Transcript Medical Review Team

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
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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
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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
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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 450B, 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
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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
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Area Agency on Aging (AAA) Responsibilities
Aging and Disability Resource Centers (ADRCs)
• Issue Form 4B and send 4B, Level II evaluation, certification,
and related paperwork to NF
• A 4B 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
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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
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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
 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
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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 and forwards the
AAA to complete the 4b 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)
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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
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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
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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
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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)
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Eligibility Process
Initial Referrals
• The following steps must be completed to ensure the eligibility
file for an initial referral is loaded to IndianaAIM:
–AAA must complete a 4B on all new referrals to the CMHC
•
Send 4B 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
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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 IndianaAIM:
–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
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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 interChange,
or the 837P transaction, within one
year from the date of service
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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
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Procedure Codes
PAS MR/DD Level II
• T2011 U1 UA – Fee $355.00
–T2011: Pre-Admission Screening Resident Review
(PASRR) Level II Evaluation, per Evaluation
–U1: PAS (Pre-Admission Screening)
–UA: Mental Retardation / Developmental Disability
• T2011 U1 UA H1 – Fee $150.00 (psych exam)
–T2011: Pre-Admission Screening Resident Review
(PASRR) Level II Evaluation, per Evaluation
–U1: PAS (Pre-Admission Screening)
–UA: Mental Retardation / Developmental Disability
–H1: Integrated Mental Health and Mental Retardation /
Developmental Disabilities Program
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Procedure Codes
PASRR MR/DD Level II
• T2011 U2 UA – Fee $355.00
–T2011: Pre-Admission Screening Resident Review
(PASRR) Level II Evaluation, per Evaluation
–U2: RR (Resident Review)
–UA: Mental Retardation / Developmental Disability
• T2011 U2 UA H1 – Fee $150.00 (psych exam)
–T2011: Pre-Admission Screening 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
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Procedure Codes
PAS MI Level II
• T2011 U1 UB – Fee $322.00 ( initial)
–T2011: Pre-Admission Screening Resident Review
(PASRR) Level II Evaluation, per Evaluation
–U1: PAS (Pre-Admission Screening)
–UB: Mental Illness
• T2011 U1 UB TS – Fee $143.50 (follow-up)
–T2011: Pre-Admission Screening Resident Review
(PASRR) Level II Evaluation, per Evaluation
–U1: PAS (Pre-Admission Screening)
–UB: Mental Illness
–TS: Follow-up service
PRE-ADMISSION SCREENING RESIDENT REVIEW
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Procedure Codes
PASRR MI Level II
• T2011 U2 UB – Fee $322.00
–T2011: Pre-Admission Screening
and Resident Review (PASRR)
Level II Evaluation, per
Evaluation
–U2: RR (Resident Review)
–UB: Mental Illness
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Remittance Advice
• Providers receive a Remittance Advice (RA) each week if
IndianaAIM has claims in the processing system
– RAs are posted at the beginning of each week on
Web interChange
– 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
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Top Denial Reasons
PRE-ADMISSION SCREENING RESIDENT REVIEW
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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
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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
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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
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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
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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
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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
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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
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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 4B 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
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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 [email protected] or call (317) 232-7858
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Questions
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October 2009