Conducting Home Assessments and Developing a Plan of Care POC

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Conducting Home Assessments andDeveloping a
Plan of Care (POC)

• Department of Medical Assistance Services
• www.dmas.virginia.gov

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Top Five List of Most Common Problems with
Assessments POCs

• 5. The recipient and/or family determines the
  amount of hours on the POC.
• 4. A POC is developed that is not based on the
  needs of the recipient. There is little to no
  justification documented for the request of time
  on the POC.
• 3. The recipient does not have a backup support.
• 2. The DMAS-98 and the POC have different amount
  of time per week and/or incorrect total hours.
• 1. The POC is not filled out completely.

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Assessing the Needs of the Recipient

• The needs of the recipient are considered
  independent of the needs of others in the home.
• The allocation of time cannot exceed the maximum
  allowed under the level of care without
  appropriate documentation and justification and
  prior approval.

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Purpose of an Assessment

• To determine the amount of time needed to provide
  the care to the recipient.
• To determine if the needs of the recipient can be
  met in the home environment.
• To determine if the recipient needs can be met by
  an attendant/personal care aide.
• To determine what other services i.e. skilled
  care, DME, transportation, DSS or other community
  services, could be utilized by the recipient.

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When is an Assessment Conducted?

• This is done on the initial Comprehensive Visit
  and every six months as a Reassessment Visit
• This must be documented on the Community-Based
  Care Recipient Assessment Report (DMAS-99), and
  must include
• A complete review of the individual's needs,
  available supports, a review of the Plan of
  Care.

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Steps to an Assessment

• Read and question the information on the UAI and
  any other information received when the recipient
  is referred for EDCD services.
• Plan the initial assessment with
  family/significant others and/or caregivers
  present, if possible.

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Steps to an Assessment - continued

• Discuss with the recipient/caregiver the need for
  the request to be accurate and reasonable. An
  example is if the recipient/caregiver tells you
  it takes 2 hours for a bath, you need to ask what
  makes the bath take 2 hours? Or if you are told
  there are 3 hours of housekeeping per day you
  need to question what the attendant/personal care
  aide is expected to clean during this period of
  time and why it would take this much time. 3
  hours per day/7 days per week is equivalent to 21
  hours per week of housekeeping. This would be
  considered unreasonable.
• Discuss each item listed on the DMAS-97A/B with
  the recipient/caregiver and give an opportunity
  for discussion.

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Steps to an Assessment - continued

• If the recipient is a transfer from another CD
  provider or PC provider, do not assume that the
  number of hours the recipient tells you they had
  been receiving is correct or can be justified. A
  new assessment must be done prior to sending in a
  request to the preauthorizing agent. The
  recipient status may have changed and/or they may
  require more or less time than they had been
  receiving in the past.

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Developing the Plan of Care

• Although the EDCD Waiver Manual states that you
  do not have to assign times to each of the 19
  specific personal/respite tasks listed on the
  DMAS-97A/B, it is good to do this until you have
  done several POCs. This can be used as an
  instrument to assist you in knowing which items
  on the list have unreasonable amounts of time
  associated with them and if you need to adjust
  the total hours.

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Developing the Plan of Care continued

• Tasks should not be taken independent of each
  other because it is usual for tasks to be done at
  the same time. An example would be the laundry is
  going while lunch is being cooked and the
  recipient is toileting.

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Developing the Plan of Care continued

• The DMAS-97-A/B must be completed by the SF prior
  to the start of care for any recipient.
• The plan of care indicates the general needs of
  the recipient.

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Allocation of time

• Time does not need to be allocated for each of
  the 19 tasks on the Plan of Care, each
  sub-category should be totaled if time has been
  allotted to that category.
• During the initial contact with the recipient the
  SF must determine the needs of the recipient not
  only by discussion with the recipient but by
  observation and assessment.

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Requesting Pre-Authorization (PA) of Services
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How Do I Submit the PA Request

• All requests must be submitted to the CBC review
  unit of the PA contractor.
• Submit enrollments via fax or mail.
• Do not use a public fax , or any that would
  violate HIPAA. (including friends, family,
  etc.)
• Submit changes in services via phone, fax, or
  mail.
• For all telephonic requests, the analyst may
  request additional information, by fax or mail,
  before a final decision is made.

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How Do I Submit the PA Request

• The request must be received within ten (10)
  business days of the initiation of services, or
  when you receive verification of Medicaid
  eligibility from DSS.
• Requests that do not include hours above the
  level of care are processed within ten (10)
  business days.

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How Do I Submit the PA Request

• Requests that include hours above the level of
  care, or for supervision, are processed within 24
  hours. The request must be received via fax
  before 300 p.m.
• Respite care requests are processed within ten
  (10) business days.
• Respite requests must include the name of the
  primary care giver (PCG) and where the PCG
  resides. This must be documented on the DMAS-98.

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PA Request Packet for CD Services

• The Uniform Assessment Instrument (UAI), twelve
  pages altogether
• The Pre-Admission Screening Authorization
  (DMAS-96). Must be dated prior to the start of
  waiver services
• The Screening Team Plan of Care (DMAS-97) or
  DMAS-300 for Respite Care if respite is the sole
  service

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PA Request Packet for CD Services

• The Community-Based Care Recipient Assessment
  Report (DMAS-99)
• The instructions are attached to the form.
  Including the instructions, there should be six
  pages.
• Under Support Systems The person providing
  the plan of care refers to the person PCA. The
  person directing the care may or may not apply.
  This refers to a recipient who has someone
  managing his/her POC. The person directing the
  care and the assistant cannot be the same person.

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PA Request Packet for CD Services

• The Provider Plan of Care (DMAS-97A/B)
• The DMAS-101 for recipients with mental illness
  or mental retardation and
• The Patient Information Form (DMAS-122), if the
  DMAS-122 is available at the time of submission
  of the admission package. The provider will
  retain the originals.

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PA Request Packet for CD Services

• Request for Services Form (DMAS-98). This must be
  filled out the necessary information, as follows
• Recipient and Provider information
• Recipient phone number
• Recipient Social Security number
• Request information
• Provider number/name
• National Procedure Code
• Utilize abbreviations for services used on the
  back of the form

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PA Request Packet for CD Services

• DMAS-98 (cont)
• Request Type Enrollment, change, or transfer
• Units indicate the hours requested for the
  service based upon the plan of care. If the
  request is a change, indicate the total hours
  requested
• Effective date the date to begin receiving
  services
• Date Provider received the DMAS-122
• Provider comments used to communicate
  nonclinical information regarding your request
  and
• Recipient phone for CD recipients.

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PA Request Packet for CD Services

• One line for each service requested.
• If the service is not requested on the DMAS-98,
  it will NOT be processed even if documentation
  suggests the need for preauthorization.
• The recipient phone number, social security
  number and the national codes are all required
  elements on the DMAS 98 form.

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PA Request Packet for CD Services

• Authorization for respite care may be made by the
  pre-authorization contractor as a sole service,
  or may be added for a recipient already receiving
  personal care or ADHC services. When respite is
  added as an additional service, the
  pre-authorization contractor must be contacted
  for authorization of the addition of respite
  services.

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Pre-Authorization (PA) Decisions

• You will receive one of five decisions
• Approval Partial Approval Pend Rejection or
  Denial
• Approval the service and the full requested
  amount of service is approved.
• Partial Approval the service is approved, and a
  part of the amount of the service is approved,
  but not all that is requested. Additional
  information may be requested for further review.

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Approved, Pended, Rejected, or Denied

• Pend the authorization request has been
  reviewed and before a final decision can be made
  information will be needed. The additional
  information will be written on the DMAS-98 and
  faxed to the provider.
• Reasons for Pends Incomplete and/or missing
  forms, additional information is needed.
• Requested information must be submitted within 14
  calendar days in order to have the authorization
  retroactive to the initial start of care date.

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Approved, Pended, Rejected, or Denied

• Pend (cont) You do not have to resubmit your
  entire package, only send the information or
  form(s) that is being requested by the PA
  contractor.
• Important to use your original DMAS-98 and write
  PEN RESPONSE on the top of the form.
• Rejection The request for authorization had
  numerous errors and missing information to assess
  the case.
• The provider will be notified by fax, using the
  original DMAS-98.

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Approved, Pended, Rejected, or Denied

• Rejection (cont)
• Provider must RESUBMIT the entire authorization
  request along with the information that was
  incorrect or missing from the previous
  submission.
• Use a New DMAS-98 form to resubmit request.
• Denial The type of waiver service the amount
  of service requested is completely denied. There
  can be various reasons for a denial.

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Approved, Pended, Rejected, or Denied

• Denial (cont)
• If the provider disagrees with the decision of
  the PA contract, they may request a
  reconsideration of that decision.
• Reconsiderations are reviewed by the PA
  contractor supervisor.

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WVMI Tracking Number

• 9-digits.
• Recipient and Waiver Specific.
• Provides for quick identification.
• Assigned to all decisions and entered on the
  original request for services form - DMAS 98.
• Use on all correspondence with WVMI.

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PA Number

• It is assigned by the First Health system.
• It is on the First Health authorization letter.
• Include this on the DMAS 98 when requesting a
  change of services (Changes include increases,
  decreases, transfers and discharges/deaths), or
  a change in the amount of services.

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PA Reconsideration Request

• For denials only (not rejects or pends).
• Requests may be mailed or faxed.
• Include information that justifies your request.
• Must be received within 30 days of the date of
  the denial.
• Reconsideration decision will be made within 10
  business days.
• Written response will be faxed or mailed to
  provider.

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Reconsiderations Appeals

• If services have not been rendered, the Medicaid
  recipient may request an appeal within 30 days of
  the written notification of the denial.
• If services have been rendered, the provider may
  appeal the adverse decision in writing within 30
  days of the written notification of the denial.
• Appeal requests are sent to the Appeal Division
  at DMAS.

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What If 1?

• The recipient does not meet the level of care
  criteria for waiver services
• request LOC review by DMAS
• Send DMAS the latest DMAS-99 copy of the UAI.
• TO LOC ReviewsLong Term Care Division600 East
  Broad StreetSuit 1300Richmond, VA 23219

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What If 2?

• The recipient transfers FROM another SF
• Obtain the previous provider(1) the original
  screening other associated paperwork
• (2) copy of the plan of care
• (3) the current DMAS-122, with the patient
  pay, if applicable.
• The SF schedules a home visit to conduct a
  Reassessment of the recipient needs

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ContWhat If 2?

• Create a new plan of care on the DMAS-99. The SOC
  date is the date that you conducted the
  Reassessment Visit.
• Fax or mail to WVMI (1) DMAS-98 and (2)
  DMAS-99

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What If 3?

• The recipient transfers TO an agency?
• Give the new agency the original screening
  paperwork related paperwork, including the
  current DMAS-122. Keep a copy for your own files
• Give the new agency a copy of the current plan of
  care and
• Fax WVMI the DMAS-98 with the last date of
  service (LDOS).

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What If 4?

• The recipient is going to a nursing facility
  (NF)?
• Give the original screening paperwork to the NF,
  along with the current DMAS-122. Keep a copy of
  these for your records
• Fax WVMI a DMAS-98 with the last date of service.

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• www.dmas.virginia.gov

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