Fill - Free fillable All 190 0 (Commonwealth of Massachusetts) PDF form

Commonwealth of Massachusetts

Executive Office of Health and Human Services

Office of Medicaid

600 Washington Street

Boston, MA 02111

www.mass.gov/masshealth

MassHealth

All Provider Bulletin 190

May 2009

To:

All Providers Participating in MassHealth

From:

Tom Dehner, Medicaid Director

RE: Preadmission Screening (PAS-A and PAS-CR) Forms

Background

MassHealth encourages providers to submit preadmission

screening (PAS) requests online as part of its efforts to streamline

business practices.

As part of the preparation for NewMMIS implementation on May 26,

2009, the acute and chronic/rehab preadmission screening (PAS)

forms and instructions used to submit requests for elective

admissions to acute hospitals, all admissions to rehabilitation units

in acute hospitals, and all admissions to chronic disease and

rehabilitation hospitals have been revised. The new forms have

been reorganized and reflect changes in terminology. They can

now be completed online.

Please Note

• This bulletin applies to all providers, except dental providers

who are not oral or maxillofacial surgeons. Dental providers who

are not oral or maxillofacial surgeons should contact the

MassHealth Dental Customer Service Center at

1-800-207-5019 if they have any questions about MassHealth.

• The rules for requesting preadmission screening have not

changed. For acute hospital elective admissions please refer to

the administrative and billing regulations at 130 CMR 450.208.

For chronic disease and rehabilitation hospital admissions,

concurrent screenings, and conversion reviews, and for

rehabilitation units in acute hospitals, refer to 130 CMR 435.408

through 410 in the Chronic Disease and Rehabilitation Inpatient

Hospital Manual.

Changes to the PAS

Forms

The following is a summary of the changes made to the forms.

• Although longer, the forms have been simplified for ease of use.

(continued on next page)

MassHealth

All Provider Bulletin 190

May 2009

Page 2

Changes to the PAS

Forms

(cont.)

• Depending on your request, only certain pages need to be

completed. There are separate sections for new admission,

concurrent screening, conversion review, and rereview

requests.

• There are now separate sections for requesting provider,

admitting facility, and attending physician.

• Recipient ID is now called Member ID, and is 12 characters long

instead of 10.

• Provider ID is now Provider ID/Service Location or NPI.

• Admission type is now called Assignment.

• The forms are now fillable online. You can complete them on

your computer, print, and then fax or mail them. However, we

encourage you to submit your PAS requests electronically using

the Provider Online Service Center (POSC), instead of using

the telephone, fax, or mail.

Using the New PAS

Forms

You can start using the revised PAS forms immediately. Samples of

the PAS forms are attached.

Using the Old PAS

Forms

You can submit your PAS requests using the old PAS forms until

close of business Friday, May 15, 2009.

Requesting a Supply of

PAS Forms

The PAS forms can be downloaded from the MassHealth Web site

at www.mass.gov/masshealth

. These forms can also be accessed

from the POSC. Request for paper copies of this form must be

submitted in writing and faxed to 617-988-8973 or mailed to the

following address.

MassHealth

ATTN: Forms distribution

P.O. Box 9118

Hingham, MA 02043

Questions

If you have any questions about the information in this bulletin,

please contact MassHealth Customer Service at 1-800-841-2900,

e-mail your inquiry to providersupport@mahealth.net

, or fax your

inquiry to 617-988-8974.

MassHealth/Masspro Acute Preadmission Screening for Elective Admissions | page 1

MassHealth/Masspro

Telephone: 1-800-732-7337

Fax: 1-800-752-6334

Requested Screening:

Admission Concurrent/Rehab Conversion/Rehab Rereview

Submit pgs. 1, 2, & 6. Submit pgs. 3 & 6. Submit pgs. 1, 4, & 6. Submit pg. 5.

Acute

Preadmission Screening for Elective Admissions

Member ID: Member name:

DOB:

Gender:

M F

Address:

Guardian:

Guardian address:

Member (Patient) Information

Requesting Provider Information

Provider ID/Service Location: or NPI:

Specialty:

Address:

Contact name:

Tel. no.: Fax:

Name of physician contact for peer-to-peer discussion:

Tel. no.:

Availability:

Admitting Facility Information

Provider ID/Service Location: or NPI:

Name:

Tel. no.: Fax:

Address:

Attending Physician Information (at the admitting facility)

Provider ID/Service Location: or NPI:

Specialty:

Attention (contact person for the attending):

Name: Tel. no.:

Address:

PAS-A (05/15/09)

MassHealth/Masspro Acute Preadmission Screening for Elective Admissions | page 2

Admission Screening

(Be sure to complete pages 1, 2, and 6.)

Assignment (Admission type): Acute Acute rehab

Requested admission date: Requested length of stay:

Accident? Yes No Date of accident:

Type of accident: MV-Driver MV-Passenger MV-Pedestrian Work Fall

Other:

Out of state? Yes No If yes, reason:

Late submission? Yes No If yes, reason:

Hospital patient account number (if available):

Diagnosis Code Diagnosis Description

Primary Diagnosis

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

Service Code Service Description Service Date

Primary Service Code

Service Code 2

Service Code 3

Service Code 4

Service Code 5

Please describe any clinical indications for admission and/or procedures (e.g., signs, symptoms, or

test results) that may assist us in our review:

For REHAB, please include the following information:

Current medical status:

Plan of care/goals:

PT and OT (Please complete page 6 and submit with this form.):

Cognition/SLP:

Discharge plan:

MassHealth/Masspro Acute Preadmission Screening for Elective Admissions | page 3

Concurrent Screening (FOR REHAB ONLY)

(Be sure to complete pages 3 and 6.)

Current PAS#:

Hospital name:

Member name:

Requested level of care (LOC): Acute w/rehab administrative days (AD)

Acute w/rehab hospital level of care (HLOC)

Requested from date: Requested additional length of stay (LOS):

Late request? Yes No If yes, reason:

Physician contact for peer-to-peer discussion:

Name: Tel. no.:

Availability:

Clinical Information

Discharge plan:

Barriers to discharge:

Weekly team meeting results:

Estimated discharge date:

Assistance with discharge planning requested from MassHealth:

Please describe any additional clinical indications (e.g., signs, symptoms, or test results) and/or

procedures (treatments, wound measurements and descriptions, etc.) for extending the stay that

may assist us in our review:

Please include information on the continued plan of care/goals for the following:

PT and OT (Please complete page 6 and submit with this form.):

Cognition/SLP:

MassHealth/Masspro Acute Preadmission Screening for Elective Admissions | page 4

Conversion Review (FOR REHAB ONLY)

(Be sure to complete pages 1, 4, and 6)

Reason for conversion:

Admission date: Date of conversion: Requested length of stay (LOS):

Assignment/Requested level of care (LOC): Acute w/Rehab administrative days (AD)

Acute w/Rehab hospital level of care (HLOC)

Accident? Yes No Date of accident:

Type of accident: MV-Driver MV-Passenger MV-Pedestrian Work Fall

Other:

Out of state? Yes No If yes, reason:

Late submission? Yes No If yes, reason:

Hospital patient account number (if available):

Diagnosis Code Diagnosis Description

Primary Diagnosis

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

Service Code Service Description Service Date

Primary Service Code

Service Code 2

Service Code 3

Service Code 4

Service Code 5

Clinical Information

Please describe any clinical indications for admission and/or procedures (e.g., signs, symptoms, or test results)

that may assist us in our review. Include past medical history and plan of care:

Please include the following information:

PT and OT (Please complete page 6 and submit with this form.):

Cognition/SLP:

Goals:

Discharge plan:

MassHealth/Masspro Acute Preadmission Screening for Elective Admissions | page 5

Rereview

Current PAS#:

Hospital name:

Member name:

Requested level of care: Acute admit Rehab admit Extension of rehab admit

Requested from date:

Requested additional length of stay (LOS):

Late request? Yes No If yes, reason:

Please identify and address all decisions in the Admission Determination Notice with which you disagree,

and submit all additional information and documentation to support the medical necessity of the admission.

To facilitate physician-to-physician conversation:

I certify that I am the Requesting Provider/Attending Physician/Authorized Representative of the Admitting

Facility (circle one) identiﬁed on this form. I certify that the information provided on this form and on any

attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete

to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for

any falsiﬁcation, omission, or concealment of any material fact contained herein.

Name of physician the Masspro physician should contact:

Tel no.:

Availability:

MassHealth/Masspro Acute Preadmission Screening for Elective Admissions | page 6

PT and OT Information

Physical Therapy

Current Status

Treatment Plan

(also specify hours per day)

Goals

Assistive devices:

(e.g., cane/crutches/walker/

rolling walker/wheelchair)

Bed mobility

Sitting/standing balance

Transfers:

•Bed to chair

•Bathroom

Ambulation–Distance

Occupational Therapy

Current Status

Treatment Plan

(also specify hours per day)

Goals

Cognitive skills

Activities of daily living

Fine motor skills

Gross motor skills

Sensory processing

Social skills

Please include any additional information in the space below:

I certify that I am the Requesting Provider/Attending Physician/Authorized Representative of the Admitting

Facility (circle one) identiﬁed on this form. I certify that the information provided on this form and on any

attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete

to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for

any falsiﬁcation, omission, or concealment of any material fact contained herein.

MassHealth/Masspro Chronic/Rehab Preadmission Screening | page 1

Chronic/Rehab

Preadmission Screening

Member ID: Member name:

DOB:

Gender:

M F

Address:

Guardian:

Guardian address:

Member (Patient) Information

Requesting Provider Information

Provider ID/Service Location: or NPI:

Specialty:

Address:

Contact name:

Tel. no.: Fax:

Name of physician contact for peer-to-peer discussion:

Tel. no.: Availability:

Admitting Facility Information

Provider ID/Service Location: or NPI:

Name:

Tel. no.: Fax:

Address:

Attending Physician Information (at the admitting facility)

Provider ID/Service Location: or NPI:

Specialty:

Attention (contact person for the attending):

Name: Tel. no.:

Address:

MassHealth/Masspro

Telephone: 1-800-554-5127

Fax: 1-800-752-6334

Requested Screening:

Admission Concurrent Conversion Rereview (Reconsideration)

Submit pgs. 1, 2, & 6. Submit pgs. 3 & 6. Submit pgs. 1, 4, & 6. Submit pg. 5.

PAS-CR (05/15/09)

MassHealth/Masspro Chronic/Rehab Preadmission Screening | page 2

Admission Screening

(Be sure to complete pages 1, 2, and 6.)

Assignment (admission type): Chronic Rehab

Requested admission date: Requested length of stay (LOS):

Accident? Yes No Date of accident:

Type of accident: MV-Driver MV-Passenger MV-Pedestrian Work Fall

Other:

Out of state? Yes No If yes, reason:

Late submission? Yes No If yes, reason:

Hospital patient account number (if available):

Diagnosis Code Diagnosis Description

Primary Diagnosis

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

Service Code Service Description Service Date

Primary Service Code

Service Code 2

Service Code 3

Service Code 4

Service Code 5

Clinical Information

Ventilator dependent?

Yes No TBI? Yes No Tracheotomy? Yes No

Please describe any clinical indications for admission and/or procedures (e.g., signs, symptoms, or test

results) that may assist us in our review. Include past medical history and treatment/course of care at

the acute facility:

For REHAB, please include the following information:

Current medical status:

Plan of care/goals:

PT and OT (Please complete page 6 and submit with this form.):

Cognition/SLP:

Discharge plan:

MassHealth/Masspro Chronic/Rehab Preadmission Screening | page 3

Concurrent Screening

(Be sure to complete pages 3 and 6.)

Current PAS#:

Hospital name:

Member name:

Requested level of care (LOC): Chronic hospital level of care (HLOC) Rehab hospital level of care (HLOC)

Chronic/Rehab administrative days (AD)

Requested from date: Requested additional lengh of stay (LOS):

Late request? Yes No If yes, reason:

Physician contact for peer-to-peer discussion:

Name: Tel. no.:

Availability:

Clinical Information

Ventilator dependent? Yes No TBI? Yes No Tracheotomy? Yes No

Discharge plan:

Barriers to discharge:

Weekly team meeting results:

Estimated discharge date:

Assistance with discharge planning requested from MassHealth:

Please describe any additional clinical indications (e.g., signs, symptoms, or test results) and/or

procedures (treatments, wound measurements and descriptions, etc.) for extending the stay that

may assist us in our review:

For REHAB, please include information on the continued plan of care/goals for the following:

PT and OT (Please complete page 6 and submit with this form.):

Cognition/SLP:

Goals:

MassHealth/Masspro Chronic/Rehab Preadmission Screening | page 4

Conversion Review

(Be sure to complete pages 1, 4, and 6.)

Reason for conversion:

Admission date: Date of conversion: Requested length of stay (LOS):

Assignment/Requested level of care (LOC): Chronic hospital level of care (HLOC)

Rehab hospital level of care (HLOC) Chronic/Rehab administrative days (AD)

Accident? Yes No Date of accident:

Type of accident: MV-Driver MV-Passenger MV-Pedestrian Work Fall

Other:

Out of state? Yes No If yes, reason:

Late submission? Yes No If yes, reason:

Hospital patient account number (if available):

Diagnosis Code Diagnosis Description

Primary Diagnosis

Diagnosis 2

Diagnosis 3

Diagnosis 4

Diagnosis 5

Service Code Service Description Service Date

Primary Service Code

Service Code 2

Service Code 3

Service Code 4

Service Code 5

Clinical Information

Ventilator dependent?

Yes No TBI? Yes No Tracheotomy? Yes No

Please describe any clinical indications for admission and/or procedures (e.g., signs, symptoms, or test results)

that may assist us in our review. Include past medical history and plan of care:

For REHAB, please include the following information:

PT and OT (Please complete page 6 and submit with this form.):

Cognition/SLP:

Goals:

Discharge plan:

MassHealth/Masspro Chronic/Rehab Preadmission Screening | page 5

Current PAS#:

Hospital name:

Member name:

Requested level of care: Chronic Rehab Administrative days (AD)

Requested from date:

Requested additional length of stay (LOS):

Late request? Yes No If yes, reason:

Please identify and address all decisions in the Admission Determination Notice with which you disagree, and

submit all additional information and documentation to support the medical necessity of the admission.

To facilitate physician-to-physician conversation:

I certify that I am the Requesting Provider/Attending Physician/Authorized Representative of the Admitting

Facility (circle one) identiﬁed on this form. I certify that the information provided on this form and on any

attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete

to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for

any falsiﬁcation, omission, or concealment of any material fact contained herein.

Name of physician the Masspro physician should contact:

Tel no.:

Availability:

MassHealth/Masspro Chronic/Rehab Preadmission Screening | page 6

PT and OT Information

Physical Therapy

Current Status

Treatment Plan

(also specify hours per day)

Goals

Assistive devices:

(e.g., cane/crutches/walker/

rolling walker/wheelchair)

Bed mobility

Sitting/standing balance

Transfers:

•Bed to chair

•Bathroom

Ambulation–Distance

Occupational Therapy

Current Status

Treatment Plan

(also specify hours per day)

Goals

Cognitive skills

Activities of daily living

Fine motor skills

Gross motor skills

Sensory processing

Social skills

Please include any additional information in the space below:

I certify that I am the Requesting Provider/Attending Physician/Authorized Representative of the Admitting

Facility (circle one) identiﬁed on this form. I certify that the information provided on this form and on any

attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete

to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for

any falsiﬁcation, omission, or concealment of any material fact contained herein.

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