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Pas Cr (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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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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Pas Cr (Commonwealth of Massachusetts)

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Completed 27 July 2020

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