RE-DESIGNED FORMS

DA-124A; DA-124B

The screening forms, DA-124A and DA-124B, have been re-designed.  The content and organization of the forms remain fundamentally unchanged.  For DFS staff, the important change is that the Level of Care Determination portion of the DA-124A no longer contains boxes for SNF and ICF; these levels have been combined into one level, NF.  A claimant's DA-124A must indicate NF level of care in order to be approved for vendor care level of care "N".  (Vendor claimants who are not MHC or IMR placements should have level of care "N"; persons at the "I" level of care may remain at that level, but no new persons should be added at the "I" level of care.  This policy is the same as announced in IM-#135, 1990.)  For cash nursing facilities (SNC), Division of Aging's Central Office Medical Review Unit (DA-COMRU) will mark the "SNC" box in the lower right corner of the DA-124A if the claimant qualifies for the NF level of care.

There is no "DFS Certification Date" on the revised DA-124A.  The policy for determining the beginning date for vendor benefits has not changed.  That is, the date for vendor eligibility can never precede the later of the completion date of the pre-admission screening or the date of admission.  Do not use the DFS Certification Date on old DA-124C's or the PASARR date (found at the top of the revised DA-124C's) to determine the beginning date of eligibility.

NOTE ON PRIOR QUARTER COVERAGE: Chapter VI, page 17, section B, gives instructions for determining the beginning date for current eligibility.  Vendor coverage can begin in the prior quarter but never before the later of the date of admission or the completion date of the pre-admission screening, as explained on page 14, item (4), fourth paragraph, page 18, item 2.b, and page 19, fourth paragraph.

For re-admissions and re-applications, new DA-124A and DA-124B forms are not required if the "Next Evaluation Date" on the forms from the previous admission or application has not expired, the client remains in the same facility and the situation remains stable.

DA-124C

The DA-124C has been greatly revised, but its function for DFS staff will remain essentially the same.  The form will still be required by DFS to determine the beginning date of eligibility for vendor cases.  The date of the physician's signature continues to be one of the limiting factors in determining the beginning date of eligibility for vendor benefits.  The DA-124C continues to represent a Level I screening for persons who may have a mental health need.  Persons whose Level I screenings indicate such a need must be screened again (Level II) by the Department of Mental Health (DMH), and (except as noted below under "Special Admission Categories") may not be approved for vendor coverage until DMH has determined that nursing home placement is appropriate.  Thus, the policy stated in Chapter VI, page 16, "Verification of Preadmission Screening," still applies.  Persons requiring a Level II screening may be readily identified by looking for the claimant's or guardian's signature on the back of page 2 of the DA-124C in Section E, "Acknowledgment of Notice."  DA-COMRU will hold such forms until DMH has reached a decision.  A letter giving the results of the DMH determination will be attached to the DA-124C before mailing the form to the county office.

New DA-124C's are not required when:

• a case was closed and then re-opened at the same facility, provided (1) there was no break in the stay at the facility other than for hospitalization and (2) the closing was due to something other than a change in the DA Level of Care determination,

• the resident transfers directly from another facility within Missouri,

• the resident has been a nursing facility resident (either in the same or a different facility) within the last 60 days, or

• the resident leaves one facility for hospitalization and then is released directly into another facility.

• the resident moves from a non-Medicaid-certified bed to a Medicaid-certified bed, or

• the resident transfers from a facility outside Missouri.

The DA-124C provides for exceptions to Level II screening under Section D, "Special Admission Categories."  (This section replaces old Section B, "Exemption Categories.")  The purpose of the Special Admission Categories is to allow short-term stays for persons who may have mental retardation, mental illness or related conditions (MR/MI) without requiring a Level II screening.  Three of the Special Admission Categories will require special handling by DFS staff.

Respite Care: Provides for relieving family, friends or other primary in-home caregivers.  Cannot exceed 30days.

Emergency Provisional Admission: Provides for protecting the patient from serious physical harm to self or others.  Cannot exceed seven (7) days.

Direct Transfer from a Hospital: Provides for recuperative care for the same condition for which the patient was hospitalized.  Cannot exceed 30 days.  The 120-day convalescent stay for possible MR/MI patients is no longer identified as a special category.

• If the claimant's stay continued beyond the special admission period and DA-COMRU determines the claimant needed NF level of care, DA-COMRU will attach a letter to that effect to the DA-124C.  DFS staff should determine the claimant's eligibility in the same manner as for any regular admission, treating the period of the special admission as part of the regular admission for eligibility purposes.

• If the claimant's stay continued beyond the special admission period but DA-COMRU determines the claimant no longer needed NF level of care, DFS staff should determine the claimant's vendor eligibility for the special admission period.  DA-COMRU will indicate the appropriate length of eligibility (7 days or 30 days).  There will be no attachment from DA-COMRU.  If otherwise eligible, approve the case beginning with the later of the date of the special admission or date of the physician's signature on the DA-124C.  Investigate non-vendor Title XIX coverage beginning after the special admission period.  After the automated system accepts the approval, close the case if not eligible for Title XIX.  Otherwise, enter an ending date for the NG level of care and change the level of care to "T" effective for the following day.

• If the claimant's stay did not continue beyond the special admission period, approve the case (if otherwise eligible) beginning with the later of the date of the special admission or date of the physician's signature on the DA-124C.  After the approval has been accepted by the automated system, close the effective with the date the claimant left the facility.

Claimants approved under special admission categories require the same Vendor Notice (IM-62) that regular admissions do.  The method for determining surplus information is the same as for regular NF admissions.  If the claimant is in the nursing facility on the first day of the month, the surplus is effective for that month.

SUPPLIES OF FORMS; IMPLEMENTATION DATE

Initial supplies of the newly-revised forms will be sent from State Office to nursing facilities and hospitals, in addition to county DFS offices.  Counties remain responsible for maintaining supplies of all these forms to provide to local facilities after the initial distribution.  After receiving the initial supplies, do not direct facilities to State Office (either DFS or DA) for these forms.

Because the changes in the DA-124A and DA-124B are largely cosmetic, the old forms may be used until supplies are exhausted.

The DA-124C changes require that there be as little overlap between old and new forms as possible.  Distribute remaining supplies of the old version of this form to facilities only when it appears likely that they will be used before November 1, 1994.  After November 1, 1994, DA-COMRU will require that nursing facilities use only the revised DA-124C.

Do not require a revised DA-124C if an old version of the form is in the record and still valid.  Example: Augusta Tabor was admitted to Matchless Nursing Home on August 3, 1994.  The DA-124C was signed that day and there was no need for a level II screening.  Her daughter, Beverly, applied for vendor benefits for her the following day, but the case was rejected due to Mrs. Tabor's resources.  Beverly re-applies November 11, since Mrs. Tabor's resources are now depleted.  There has been no break in Mrs. Tabor's stay at Matchless in the interim.  The DA-124C of August 3 continues to meet the pre-admission screening requirement.

• Review this memorandum with all appropriate staff.

• Continue using existing supplies of DA-124A and DA-124B until supplies are exhausted.

• Distribute to local facilities only so many of the old DA-124C forms as are likely to be used before November 1, 1994.

• Destroy existing supplies of the old DA-124C by November 1, 1994.

• Distribute to local facilities only the revised DA-124C after November 1, 1994.

• File revised forms instructions.