La. Admin. Code tit. 50 § II-503

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-503 - Medical Certification

A. Evaluative data for medical certification (level of care determination) must be submitted to the Office of Aging and Adult Services (OAAS) or its designee for all initial admissions to and requests for continued stays in Medicare or Medicaid-certified nursing facilities, regardless of payer source.

1. Initial Admissions

a. Required Documents. The following documents are required for initial admission to a nursing facility. The initial admission process does not begin until all of the following documents are complete and submitted by OAAS. These documents must not be dated more than 30 calendar days prior to the date of admission and must reflect the individuals current functioning:

i. a level of care eligibility tool (LOCET) assessment;

ii. a preadmission screening and resident review (level I PASRR) form completed by a qualified health care professional. The level 1 PASRR form must be signed and dated on the date that it is completed. The level I PASRR form addresses the specific identifiers of MI or I/DD that indicate that a more in-depth evaluation is needed to determine the need for specialized services. The need for this in-depth assessment does not necessarily mean that the individual cannot be admitted to a nursing facility, only that the need for other services must be determined prior to admission;

(a). if the information on the level I PASRR indicates that the individual may have a diagnosis of MI and/or I/DD, and the individual meets the criteria for nursing facility level of care, the individual shall be referred to the Office of Behavioral Health or the Office for Citizens with Developmental Disabilities (the states mental health and intellectual disability level II authorities) for a level II screening to determine if the individual requires the level of services provided by a nursing facility and whether specialized services are needed. Medical certification is not guaranteed for an individual who has been referred for a level II screening. A Medicaid-certified nursing facility shall not admit an individual identified for a level II screening until the screening has been completed and a decision is made by the level II authority;

(b). if there is no indication on the level I PASRR or in other records that the individual may have a diagnosis of MI and/or I/DD and he/she meets the criteria for nursing facility level of care, OAAS may approve the individual for admission to the nursing facility;

iii. for nursing facility admission under a specialized level of care, additional documentation that supports the need for specialized care; and

iv. OAAS or its designee may require the submittal of additional documentation to support the need for a nursing facility stay.

b. Vendor Payment. Once approval has been obtained, the individual must be admitted to the facility within 30 calendar days of the date of the approval notice. The nursing facility shall submit a completed BHSF Form 148, immediately upon admission, to the local Medicaid eligibility office and OAAS indicating the anticipated payment source for the nursing facility services. Medicaid vendor payment shall not begin prior to the date that medical and financial eligibility is established, and shall only begin once the individual is actually admitted to the facility.

NOTE: Repealed.

2. Continued Stay Requests

a. Required documents. The following documents are required in order for OAAS or its designee to determine the need for continued services in a nursing facility. The continued stay process does not begin until all of the following documents are complete and submitted to OAAS.

i. a continued stay request form as issued by OAAS or its designee;

ii. documentation to support the request for continued stay, including the most recent MDS 3.0. A LOCET will not be accepted as sufficient evidence of medical need for an individual who has been discharged for a period of less than 14 calendar days unless:

(a). there is additional supporting documentation demonstrating a significant change in status; or

(b). the individual is seeking admission to a facility different than the facility from which they were discharged; and

iii. additional documentation as required by the level II authorities.

b. Vendor payment. Medicaid payment shall be made in accordance with the Notice of Medical Certification (BHSF Form 142) issued by OAAS or the level II authority.

A.3. - D. Repealed.

La. Admin. Code tit. 50, § II-503

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 36:1011 (May 2010), Amended by the Department of Health, Bureau of Health Services Financing and the Office of Aging and Adult Services, LR 431179 (6/1/2017), Amended LR 441018 (6/1/2018), Amended LR 442166 (12/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.