Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Office of Quality Assurance OQA-2281 (Rev. 10-06)

STATE OF WISCONSIN

CARE LEVEL CHANGE NOTICE
Facility Name City Effective Date of Action for Residents Listed in Section A License Number

SECTION A
Resident Name MA Number Previous Care Level Current Care Level SIGNATURE RN Reviewer

A facility may contest this care level change by requesting an administrative review by the Bureau of Quality Assurance. The request must be filed within 30 days of receipt of this Care Level Change Notice. The written request for an administrative review must include a copy of this notice and supporting documentation for each care level contested and be sent to: Provider Regulation and Quality Improvement Nursing Consultant Office of Quality Assurance 2917 International Lane, Suite 300 Madison WI 53704

SECTION B
Appeal notice letters will be sent to the following residents informing them that they are no longer eligible for coverage under the Wisconsin Medical Assistance Program. Effective Date of Action for Residents Listed in Section B

SIGNATURE ­ Provider

Date Signed

If you have questions regarding the care level changes you may call the Office of Quality Assurance Reviewer listed below:
Primary Team RN Telephone Number Regional Office

OQA-2281 Rev. 10-06) Page 2

INSTRUCTIONS OQA-2281 CARE LEVEL CHANGE NOTICE Complete this form for nursing facilities and facilities for the developmentally disabled. The assigned RN is responsible for the accurate completion of this form. SECTION A: Document only those residents whose care level has changed as a result of the survey process but whose care needs will continue to be met by this facility. List the name of the resident, MA number, previous care level (nursing/DD/MI) and current care level (Nursing/DD/MI) and sign with a complete signature (not initials). NOTE: The effective date is the date served. SECTION B: Document only those residents who no longer are eligible for coverage under the Wisconsin Medical Assistance Program because their needs no longer qualify them for care at this facility. Note: Section B residents receive notice of non-coverage via certified mail. The effective date of non-coverage is always the 1st working day of the month following a ten calendar day notice plus 5 calendar days for mail delivery.

EXAMPLE 1: Letter mailed to resident on March 10; add 5 calendar days for mail delivery; add 10 calendar days for notice of non-coverage = March 25. Effective date would be the first working day in April. EXAMPLE 2: Letter mailed to resident on March 20; add 5 calendar days for mail delivery; add 10 calendar days for notice of non-coverage = April 4. Effective date would be the first working day in May. Provider signs and dates this form to indicate that the facility has received notice of the care level changes and the facility administrative review rights for those residents listed in Section A of this form.