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Free 49120.FH11 - Indiana



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Excerpt: NURSING FACILITY LEVEL OF SERVICE STATE AUTHORIZATION AND DATA ENTRY State Form 49120 (11-98) / OMPP 450B SA/DE Indiana Family and Social Services Administration (FSSA) CONFIDENTIAL MEDICAID STATUS Medicaid Pending Medicaid Recipient Non-Medicaid Reset Form Disclosure of information requested is MANDATORY and CONFIDENTIAL pursuant to IC 12-15-2, IC
NURSING FACILITY LEVEL OF SERVICE STATE AUTHORIZATION AND DATA ENTRY
State Form 49120 (11-98) / OMPP 450B SA/DE Indiana Family and Social Services Administration (FSSA)

CONFIDENTIAL

MEDICAID STATUS Medicaid Pending Medicaid Recipient Non-Medicaid

Reset Form

Disclosure of information requested is MANDATORY and CONFIDENTIAL pursuant to IC 12-15-2, IC 12-21 and 470 IAC 1-3-1. INSTRUCTIONS: NOTE: This form may be utilized in place of the Form 450B "Physician Certification for Long Term Care Services" for persons already in a nursing facility (NF) and only in the following situations: 1. PAS/PASRR, onset of NEW MEDICAID (private pay to Medicaid recipient), and NURSING FACILITY to NURSING FACILITY TRANSFERS when a fully completed MDS (Initial, Quarterly , or Significant Change for the period under review) is available. A copy of the applicable MDS must be submitted with this form in place of the Form 450B. NOTE: The Physician Orders for the NF care must be in the resident's records and available for audit. READMISSION to any NF after the 15-day bed-hold from a hospital stay, to reinstate Medicaid reimbursement for persons who have a State authorization for Medicaid reimbursement for NF care prior to the hospitalization (No MDS is required). Please specify the "from and through" dates of the hospitalization in Section I below.

2.

Evidence of PAS (4B) must be attached if the request for Medicaid reimbursement is for a time period less than one year from the initial admission. PASRR: Note, there are no changes in the PASRR program requirements or procedures other than the State allowing the MDS to be used in place of the Form 450B for individuals who are already in the NF. The Form 450B may continue to be used. A fully completed Form 450B, including the physician's signature, must continue to be submitted in any situation where the NF does not have a completed MDS for the resident or chooses not to submit the MDS in place of a Form 450B. Submit either a complete, physician signed Form 450B or this form with a copy of the applicable complete MDS. PLEASE DO NOT SUBMIT BOTH Form 450B and the MDS. SECTION I - RECIPIENT IDENTIFICATION
Name of applicant (last, first, middle) Name of NF (stamp or label accepted) Address of NF (number and street) City, state, ZIP code Resident admitted from: Date of birth (month, day, year) NF admission date (mo., day, yr.) Re-admission date from hospital Discharge date (if applicable) Sex Name of county

Medicaid number (RID) Social Security number New Medicaid eligibility date Request length of care

a. Home b. ICF/MR c. Psychiatric Bed
This certification is for:

d. Acute Care Hospital - From _______________ Through ___________________ e. NF Facility _______________________________ f. ARCH / RBA / Residential g. Out-of-State ___

Short-term NF provider number

Long-term

Medicare from/through dates

h. Other _______________________________
Date data entered Comments:

SECTION II - STATE AUTHORIZATION Admission Approved
Authorized signature:

Readmission Disapproved

Continued Care
Effective Medicaid reimbursement date Date signed (month, day, year)

IFSSA
MEDICAID only:

Area PAS agency
Rvwr ID LOC code Start Rsn Start date Stop Rsn Stop date Prior Res Empty Bed

RESIDENT COPY

Resident Appeal Rights / How to Request an Appeal

If you are not satisfied with this decision, you may request an appeal within 30 days of the date of receipt of this decision. Sign and return this form or send a letter with your signature to: MS04, Indiana Family and Social Services Administration, Hearings and Appeals, 402 W. Washington St., Rm. W392, Indianapolis, Indiana 46204. (IC 12-15-28 and 405 IAC 1.1-1) Be sure that the letter contains your address and a telephone number where you can be reached. It is also helpful if you describe the nature of the action you are appealing, if you are not using this form to request the appeal. If you are unable to write this letter yourself, you may have someone assist you in requesting this appeal. You will be notified in writing by IFSSA Hearings and Appeals of the date, time and place for the hearing. Prior to, or at the hearing, you will have the right to examine the entire contents of your case record. You may represent yourself at the hearing or authorize a representative such as an attorney or other spokesperson to do so. At the hearing you will have full opportunity to bring witnesses, establish all pertinent facts and circumstances , advance any arguments without interference and question or refute any testimony or evidence presented. I wish to appeal the above decision.
Signature of resident / guardian

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