Free 47184.pdf - Indiana

INDIANA PASARR / MI PROGRAM CMHC ARR REFERRAL CHECKLIST
State Form 47184 (9-95) / BAIS 0031

When completed, mail to: PASARR / MI Program DDARS-BAIS 402 West Washington Street, Room W454 P.O. Box 7083 Indianapolis, Indiana 46207-7083 Page ________ of ___________ .

READ THE INSTRUCTIONS ON THE REVERSE SIDE.
1. Name of the Community Mental Health Center City

2. NF name

3. NF address (number and street, city, state, ZIP code)

4. Date:

Routine: LTC Review Team NF Visit ________ / ________ / ________ / (Lower right-hand corner of worksheet) Non-Routine: NF Referral Letter / Other ________ / ________ / ________ / (Date on NF letter)
If "Other", please explain:

In hospital bed

In NF

Referral Letter Received from NF ________ / ________ / ________ ("Date-Received" stamped on NF referral letter by CMHC)
5. Date: Title

6. Prepared by: (name)

Date (month, day, year)

8. Check one 7. REFERRAL LIST: (Use name(s) or list supplied by NF.) Name: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. ROUTINE: Attach Level II and LTC Review Team's Audit Worksheet Last First M.I. Medicaid PrivPay

9. Date Last L-II Assmt

10. Check one Purpose ARR PAS

11. Date L-II Scheduled

12. Date L-II Completed

NON-ROUTINE: Attach NF Referral Letter, Level I, Form 450B, Level II (and, if readmitted from hospital, Letter of Assurance) NOTE: Case records will be sent to NF with determination letter. CMHC will be sent a copy of each deterimination letter only for the CMHC files. CMHC should keep a clear copy of all documents submitted to the State PASARR / MI Unit on file at the CMHC.

INSTRUCTIONS CMHC ARR REFERRAL CHECKLIST Indiana PASARR / MI Program
Complete one form for each Nursing facility (NF) referral or list received. Attach additional pages as needed.Use the written referral from the NF to complete the information requested. Contact the NF for missing information. 1. 2. 3. 4. Enter the name and city of your Community Mental Health Center (CMHC). Enter the name of the particular NF whose residents are being referred for ARR. Enter the complete address of the NF, including ZIP code. Check the appropriate box for "Routine" or "Non-Routine" ARR. A. ROUTINE ARR: Enter the date of the LTC Review Team's NF visit. This date is the certification date in the lower right-hand corner of the LTC Review Team's Audit Worksheet (Level of Care Payment Review / PASARR / Nursing Facilities "sideways sheet"). B. NON-ROUTINE ARR: Enter the date on the referral letter sent by the NF. (For each Non-Routine ARR, also attach the NF referral letter, new Level I, new 450B form, and when readmitted to the NF from psychiatric hospitalization, the assurance letter from the hospital.) NOTE: Always batch routine and non-routine ARRs separately, using a separate Checklist for each. Use a new CMHC ARR Referral Checklist for each individual non-routine ARR case. 5. Enter the date the CMHC received the written referral for ARR Level II from the NF (as date-stamped by the CMHC on the referral NF letter or form). 6. Enter the name and title of the person preparing this form. Enter the date the form was completed. 7. Enter the last and first name of each resident on the ARR list received from the NF, regardless of need for Level II. Each referral must be accounted for with either a Level II or Inappropriate Referral. 8. Place a check in one of these columns for each resident listed in number 7 to identify the payment status of each. If not indicated on the NF listing, the status may be found in the upper left-hand corner of each Medicaid LTC Review Team Audit Worksheet. Residents who are Medicaid recipients will show a Medicaid RID; residents who are private-pay will have a Social Security number in the Medicaid RID space. 9. Enter the date of the last Level II Assessment (This is the latest psychiatrist's signature date on the Level II assessment.) If a Level II has never been done before, enter the word "None" or other explanation. 10. Place a check in one of these columns for each resident to show the purpose of the last Level II assessment. If it was for an ARR, check that column; if for PAS, check that column. If the resident has never been assessed under Level II, and this referral is for the onset of a new MI condition, write "New" in the appropriate column. If the resident has a long-standing MI condition or history of MI treatment which should have been assessed under Level II, but no Level II has been done, write "None" in this column. 11. Enter the projected date of the Level II Assessment as scheduled by your CMHC. ROUTINE ARR: At this point, submit a pre-assessment copy of the CMHC ARR Referral Checklist to the State PASARR / MI Program for required tracking purposes. Retain a copy to submit with the batch of completed Level II Assessments. Do not submit a pre-assessment copy of the Checklist. Non-routine ARRs are to be completed as soon as possible within the quarter of the referral. Attach the completed Checklist to the case packet when it is submitted to the State.

NON-ROUTINE ARR:

12. Enter the date the ARR Level II Assessment was completed. (This will be the date of the psychiatrist's signature on the Level II Assessment.) Place a copy of this completed form on top of the batch of completed Level II assessments, with the appropriate documentation (for routine ARRs: the Medicaid NF Audit Worksheet; or, for non-routine ARRs: the items addressed in number 4B above) attached to each Level II prior to sending it to the State PASARR / MI Unit.