Fillable Ltc 99 (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Ltc 99 (Commonwealth of Massachusetts) Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ltc 99 (Commonwealth of Massachusetts)

On average this form takes 20 minutes to complete

The Ltc 99 (Commonwealth of Massachusetts) form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 78 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another 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
Long Term Care Facility Bulletin 99
May 2009
To:
All Nursing Facilities and Chronic Disease and Rehabilitation Inpatient Hospitals
Participating in MassHealth
From:
Tom Dehner, Medicaid Director
RE: Revised Status Change for Members in a Nursing Facility or Chronic Disease
and Rehabilitation Inpatient Hospital (SC-1) Form
Background
The Status Change for Members in a Nursing Facility or Chronic
Disease and Rehabilitation Inpatient Hospital (SC-1) Form has been
redesigned for NewMMIS implementation. The new form will allow
MassHealth to collect additional statistical data about its members.
The form now has three distinct sections. Instructions to fill in the
form are provided on page two of the form. Some of the major
changes for each section of the SC-1 form are described below.
Please Note: This form will no longer be used for rest home
residents. A new form, the Status Change for Residents in a Rest
Home (SC-1-RH) Form, has been designed for rest home members
only.
Section 1 Item 1: Provider ID/Service Location
With the implementation of NewMMIS, all MassHealth providers will
have a provider identifier and service location code. This will be a
nine-digit number followed by a one-character service location code.
Enter this number in Item 1 of the SC-1 form.
Item 12: Member ID or SSN
With the implementation of NewMMIS, all MassHealth members will
be given a unique member identification number that is not their
social security number (SSN). The new MassHealth cards will
display the member ID number instead of the SSN.
If this number is available, enter it in Item 12 of the SC-1 form. If the
individual listed on the SC-1 form is a MassHealth applicant but has
not received a member ID number yet, enter their SSN. To access
member ID information, go to the NewMMIS eligibility verification
system (EVS), the former REVS.
(continued on next page)
MassHealth
Long Term Care Facility Bulletin 99
May 2009
Page 2
Section 2 Item 15: Admitted From
Enter the living situation the individual was residing in prior to
admission. It could be home/community, hospital, nursing facility,
or rest home.
Item 18: Discharge Reason
This item includes the types of living arrangements mentioned
under Item 15, and lists reasons for discharge. If none of the
reasons applies, use the “Other” field to explain.
Section 3 Item 20: Reason for MassHealth Requested Payment Date
This item allows the nursing facility staff to inform the MassHealth
Enrollment Center (MEC) staff why they are requesting a specific
MassHealth start date (e.g., the individual paid privately through a
certain date).
Item 21: Length of Stay for Nursing Facility Services
If the short-term box is checked on the SC-1 form, a physician’s
signature is needed, and the Clinical Eligibility Determination Form
should also show a short-term approval. If the physician indicates
short-term, but the Clinical Eligibility Determination Form indicates
more than six months (formerly long-term approval), the clinical
approval overrides the physician’s statement of short-term stay.
Item 22: Clinical Eligibility for Nursing Facility Services
This item lists the type of approval or denial, and an effective date
of the decision. If clinical eligibility is denied, the facility will not be
paid. The effective date of the decision is the date located in the
lower-left corner of the Clinical Eligibility Determination Form.
Item 30: Managed Care Organization (MCO) Coverage
The nursing facility must inform the MEC staff if the
institutionalized individual was a member of a managed care
organization (MCO), Program for All-inclusive Care for the Elderly
(PACE), or Senior Care Options (SCO), and when the coverage
ended. However, this end date is not applicable to SCO and
PACE.
Please Note: MCO plans include a nursing home component, and
a certain number of days may be paid for by an MCO for a
member in a nursing facility.
(continued on next page)
MassHealth
Long Term Care Facility Bulletin 99
May 2009
Page 3
Section 3
(cont.)
Item 33: For new admission, is Level 1 OBRA/PASARR form
attached?
All members admitted to a nursing home from a hospital should
have a Level I OBRA/PASARR form completed, and this form
should be included with the SC-1 form for every new admission.
Check Yes if the form is included, and No if it is not included.
Required Action
The nursing facility must ensure that all required fields on the SC-1
form, as described on the instructions page of the form, are
completed before submission.
Please Note: If the MEC receives an incomplete SC-1 form, the
form will be returned to the nursing facility for completion. The
MEC will process the case further only when it receives the
completed SC-1 form.
Using the New SC-1
Form
You can begin using the SC-1 form starting May 26, 2009.
However, if you submit an old SC-1 form after May 26, 2009,
please make sure you include the service location along with your
provider ID.
The SC-1 form can be downloaded from the MassHealth Web site
at www.mass.gov/masshealth
. 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
A sample of the revised SC-1 form is attached.
Questions
If you have 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.
Status Change for Members in a Nursing Facility or
Chronic Disease and Rehabilitation Inpatient Hospital
(Admission or Discharge of MassHealth Members)
Commonwealth of Massachusetts • EOHHS
www.mass.gov/masshealth
SC-1 (Rev. 05/09)
SECTION 1 ( Items 1 through 12 must be completed.)
1. Provider ID/Service Location 2. Provider Name 3. Provider Telephone Number
4. Provider Address 5. Reason for Submission
New SC-1 Change to Existing SC-1
6. Member Last Name 7. Member First Name 8. Middle Initial
9. Member Home Address
10. Member Date of Birth
/ /
11. Member Gender
Female Male
12. Member ID or SSN (Provide SSN only if member ID is not available.)
SECTION 2 (Please read instructions on the back of this form for how to complete this section.)
13. Type of Status Change
Admit
Discharge
Both admit and discharge
15. Admitted From
Home/community
Hospital
Nursing facility
Rest home
16. Admission Date
/ /
17. Discharge Date
/ /
14. Type of Bed
Nursing facility
Chronic/Rehab
18. Discharge Reason
Discharged to Home/community Discharged to a rest home Other (explain):
Discharged to a hospital Left against medical advice
Discharged to a long-term-care facility Deceased. Date of death:
SECTION 3 (Please read instructions on the back of this form for how to complete this section.)
19. MassHealth Requested Payment Date
/ /
20. Reason for MassHealth Requested Payment Date
21. Length of Stay for Nursing Facility Services
Short-term (six months or less)
More than six months
Short-term-care stay terminated
22. Clinical Eligibility for Nursing Facility Services
Approved Effective date of decision:
Approved — short term
Denied
Complete Items 23, 24, 25 only if member’s expected stay is six months or less.
23. Certication of Short Term Stay. I certify that the above-named
member’s expected length of stay is ____________________ .
24. Physician’s Signature 25. Date
/ /
26. Public Rate Amount
$
27. Private Rate Amount
$
28. Medicare Upon Admission?
Yes No
29. Medicare End Date
/ /
30. Does member have managed care organization (MCO), Program for All-Inclusive Care for the Elderly (PACE), or
Senior Care Options (SCO) coverage?
Yes No
31. MCO End Date (N/A for SCO/PACE)
/ /
32. Is the nursing facility clinical eligibility determination form attached?
Yes No
33. For new admission, is Level 1 OBRA/PASARR form attached?
Yes No
34. Signature of authorized representative completing the SC-1 form. 35. Date
/ /
/ /
/ /
SEE REVERSE SIDE FOR INSTRUCTIONS.
Reset Form
INSTRUCTIONS FOR COMPLETING THE SC-1 FORM (PLEASE PRINT OR TYPE.)
Below are instructions for specic elds. All other elds are self-explanatory. For all items with check boxes, please make sure you check one
box. As noted below, some elds are required to be completed.
SECTION 1
Items 1 through 12 are required to be completed on all SC-1 forms.
Item 1 Provider ID/Service Location Enter the nine-digit provider ID followed by the one-character location code.
Item 12 Member ID or SSN Enter the 12-digit MassHealth member ID number. Enter the social security number (SSN) only if
member ID is not available.
SECTION 2
Item 13 is required to be completed.
If Item 13 is “Admit,” items 14-16 are required to be completed.
If Item 13 is “Discharge,” items 17-18 are required to be completed.
If Item 13 is “Both admit and discharge,” items 14-18 are required to be completed.
Item 18 Discharge Reason Select the reason for discharge. If none of the reasons explains the situation clearly, use the other
eld to explain.
SECTION 3
If Item 13 is “Admit” or “Both admit and discharge,” items 19-22 and 26-33 are required to be completed.
If Item 21 is “Short-term (six months or less),” items 23-25 are required to be completed.
Items 34-35 are required to be completed on all SC-1 forms.
Item 19 MassHealth Requested Payment Date Enter the start date for which MassHealth payment is requested.
Item 20 Reason for MassHealth Requested
Payment Date
Describe the reason for the request date in Item 19 (e.g., Medicare days ended, private pay ended).
Item 21 Length of Stay for Nursing Facility
Services
The nursing facility should enter the information as it appears on the clinical eligibility determination
completed by MassHealth or its agent.
Item 22 Clinical Eligibility for Nursing Facility
Services
The nursing facility should enter the information as it appears on the clinical eligibility determination
completed by MassHealth or its agent. If clinical eligibility for MassHealth payment of nursing facility
services has been denied, do not submit this form as the facility will not be paid.
Item 26 Public Rate Amount Enter the public facility rate for this member.
Item 27 Private Rate Amount Enter the private facility rate for this member.
Item 32 Is the nursing facility clinical eligibility
determination form attached?
Check the “Yes” box if the nursing facility screening notication form is attached. Otherwise, check
“No.” If the form is not attached, the member will not be coded for long-term-care services.
Item 33 OBRA/PASARR form attached? For new admissions only, check the “Yes” box if Level 1 OBRA/PASARR form is attached to the SC-1
form. Otherwise, select “No.”
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Ltc 99 (Commonwealth of Massachusetts)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document