This chapter contains the following topics:

Topic

1001.00 General Information About the PAS

1002.00 Goal of PAS

1003.00 PAS Performed by Registered Nurse or Social Worker

1004.00 Medical Eligibility Specialist Responsibilities for Completing the PAS   Process

1005.00 Other Medical Eligibility Specialist Responsibilities

1006.00 PAS Timeframes/Timeliness

1007.00 Using an Eligible PAS within 60 days

1008.00 Developmentally Disabled (DD) Status

1008.01

Children with Developmental Delay

1008.02

Changing DD Status

1009.00 Preadmission Screening for the Elderly and Physically Disabled (EPD)

1010.00 Preadmission Screening for the Developmentally Disabled (DD)

1011.00 Completion of PAS for Hospitalized Customers

1012.00 Completion of PAS for Ventilator Dependent Customers

1013.00 Posthumous PAS

1014.00 Private Request PAS

1015.00 Level of Care

1015.01

Level of Care Methodology (EPD)

1016.00 PAS Reassessments

1017.00 Eligibility Review

1018.00 Customer Issue Referrals

1018.01

Severity Status Levels

1018.02

Discussion with Supervisor Prior to Referral

1019.00 Preadmission Screening and Resident Review (PASRR)

1020.00 First Continuous Period of Institutionalization/Community Spouse Resource Allowance

1021.00 The ALTCS Transitional Program

1021.01

PAS Medical Eligibility for ALTCS Transitional

1021.02

Transition of Customers into ALTCS Transitional Program

1021.03

ALTCS Transitional Covered Services

1021.04

ALTCS Transitional Notification/Effective Date

1021.05

ALTCS Transitional Customers Requiring Short Term NF Placement

1021.06

Reassessment of the ALTCS Transitional Customer

1022.00 Quality Control

Appendix 10A, Preadmission Screening Manual for Elderly and Physically Disabled (EPD) (PDF, 286KB)

Appendix 10A1 - ALTCS Overview

Appendix 10A2 - PAS Tool Matrix

Appendix 10A3 - Scoring Flow Chart

Appendix 10A4 - Level of Care Matrix

Appendix 10A5 - Glossary of Terms

Appendix 10A6 - Glossary of Abbreviations

Appendix 10A7 - FCPI/CSRD

Appendix 10B, Preadmission Screening Manual for Developmentally Disabled (DD) (PDF, 537KB)

Appendix 10B1 - PAS Tool Matrix by DD Status and Age

Appendix 10B2 - Glossary of Terms

Appendix 10B3 - Glossary of Abbreviations

The ALTCS Eligibility Administration (AEA) within the AHCCCS Division of Member Services is responsible for determining medical eligibility for ALTCS. Medical eligibility is determined by the Preadmission Screening (PAS) process. There are two PAS instruction manuals (Appendices 10A and 10B to this chapter) and five PAS tools used in the process of determining medical eligibility. The PAS instructions and tool used to assess ALTCS customers who are elderly and/or physically disabled (EPD), are referred to as Appendix 10A in the ALTCS Eligibility Policy and Procedure Manual. Customers who are developmentally disabled (DD) over age 6 who are residing in nursing facilities are also assessed using the EPD PAS tool. The population assessed with the DD instruction and tools, referred to as Appendix 10B, includes persons with Developmental Disabilities (DD) of all ages and children with physical disabilities under six years of age (who are not clients of DES/DDD) who apply or are currently customers of ALTCS. Refer to Appendix B1 of Appendix 10B (the DD PAS instructions) for the PAS tool Matrix by DD status and age.

The goal of PAS is to ensure proper eligibility determination of ALTCS customers. Only customers who are determined to be at risk of institutionalization and require care equal to that provided in a Nursing Facility (NF), or Intermediate Care Facility for the Mentally Retarded (ICF-MR), are medically eligible for ALTCS services.

The PAS instrument is completed by a Medical Eligibility Specialist who is a registered nurse or a social worker as follows:

A.

For both EPD and DD customers, the PAS instrument is completed by a registered nurse or social worker, who has attended a minimum of 24 hours of classroom training for each type of PAS (EPD and DD).

B.

For customers who are hospitalized, the PAS instrument is completed by a registered nurse or under some circumstances a social worker

C.

For ventilator dependent customers, the PAS instrument is completed by a registered nurse. (For more information see MS 1012)

In all cases (other than a posthumous PAS) the customer must be observed and preferably the interview occurs in the customer's usual living arrangement.

The Medical Eligibility Specialist must:

A.

Conduct a face-to-face interview with the customer;

B.

Obtain information from the caregivers and/or authorized representative;

C.

Obtain verification of major medical conditions on all cases and pertinent medical documentation on cases requiring physician review;

D.

Provide information to the customer and/or the customer's representative regarding the ALTCS program;

E.

Provide information about possible alternative services to customers who may not be ALTCS eligible;

F.

Determine whether a case requires physician review; prepare and send case for review

G.

Prepare for and conduct Pre-hearing Discussions and testify at appeal hearings

The Medical Eligibility Specialist has a variety of other duties in addition to completing the PAS.

The Medical Eligibility Specialist must:

A.

Complete PASRR Level I screening, if necessary;

B.

Determine the First Continuous Period of Institutionalization on Community Spouse cases;

C.

Complete Customer Issue Referrals, as necessary;

D.

Communicate with case managers, physicians and other health care providers;

E.

Maintain schedules of their appointments and productivity logs;

F.

Perform financial eligibility functions.

Complete the initial PAS at least six days before the end of the application period. The application period is 45 days for an ALTCS application. 

In some situations, such as a referral made by an AHCCCS Health Plan on a customer who is hospitalized, the case must be treated as a priority and the PAS must be completed as soon as possible.

Sometimes an eligible PAS is completed on a customer who is denied by the Financial Eligibility Specialist. The eligible PAS may be used for up to 60 days. This is only done when it appears the customer's condition is unlikely to improve to a point where PAS eligibility could be in question. The Medical Eligibility Specialist must verify by telephone that the customer's condition is essentially the same as on the PAS date and document in an addendum to the PAS summary. 

An ineligible PAS is never used on a new application. A eligible Private Request PAS may be used within 60 days, using the same criteria as stated above. The Private Request PAS is updated in ACE with an addendum documented in the PAS summary.

A.

Customers may be determined by the Department of Economic Security, Division of Developmental Disabilities (DES/DDD) to be eligible for DES/DDD services. DES/DDD eligible customers include those who have been diagnosed with mental retardation, cerebral palsy, seizure disorder or autism, and have significant impairment in their functional abilities. For children less than six years of age, a diagnosis of developmental delay or the risk for developmental disability may serve as the qualifying diagnosis for DES/DDD. By Arizona Revised Statute, DES/DDD is required to be the provider of services to persons with a developmental disability. 

The PAS process is intended to determine whether or not a customer's current functional abilities and medical stability, resulting from a developmental disability, indicates a need for services at the NF or ICF-MR level of care. Frequently, customers with developmental disabilities are eligible to receive services from DES/DDD but are not at risk of institutionalization at the ICF-MR level of care and therefore not eligible for ALTCS. ALTCS assigns a DD status to each case depending on their eligibility for DES/DDD services. This status is indicated on the PAS Intake Notice.

B.

The DD status classifications are as follows:

1 =

Potential DD. The customer appears to have mental retardation, cerebral palsy, seizure disorder or autism, but has not been determined to be Developmentally Disabled by DES/DDD. Refer the customer to DES/DDD for evaluation and use both DD and EPD assessment tools. If DES/DDD has not determined the DD status within 30 days, complete the EPD PAS but do not change the DD status. The Medical Eligibility Specialist may complete a DD PAS in addition to the EPD PAS pending a DES/DDD eligibility status determination on customers age six and over. A potential DD is assessed with the EPD tool, but the DD tool is required if the customer is approved by DES/DDD for services. A customer who is still pending DES/DDD eligibility will be enrolled with DES/DDD if an eligible PAS is completed. It is imperative the Medical Eligibility Specialist discuss this type of case with a supervisor prior to completing the eligible PAS. Communication must also occur with DES/DDD regarding the status of their eligibility determination. In some cases it may benefit the customer to allow DES/DDD more than 30 days to make their determination. These cases can be referred to Medical QC to assist in communication with DES/DDD.

2 =

DD. DES/DDD has identified the customer as Developmentally Disabled. Use the DD assessment tool.

3 =

DD in NF. DES/DDD has identified the customer as Developmentally Disabled and residing in a nursing facility. Use the EPD assessment tool.

4 =

Non-DD. The customer is not diagnosed as Developmentally Disabled or has a DD diagnosis but has been determined ineligible for DES/DDD services. Use the EPD assessment tool unless the customer is less than six years old.

C.

For future information on which PAS tool is used, refer to the PAS Tool Matrix by DD Status and Age, Appendix A2 of the EPD PAS manual or Appendix B1 of the DD PAS manual.

Children age six and over who are customers of DES/DDD must have one of the four DD qualifying diagnoses (mental retardation, autism, cerebral palsy, or seizure disorder) to be considered DD for their ALTCS application or reassessment. If they have developmental delay only and are over the age of five the Medical Eligibility Specialist must:

A.

Look at all available records to determine if the child has been given a diagnosis not previously found. The DES/DDD case file should contain any evaluations the child has had, but diagnoses might be found elsewhere, as well, such as medical records and school records.

B.

Contact the support coordinator if a diagnosis is not found in any of the case records reviewed. The support coordinator has a responsibility to make sure the customer is evaluated before the customer turns 6, and that the results are in the record.

C.

The Medical Eligibility Specialist must call or e-mail the AHCCCS Central Office ALTCS Eligibility Administration (AEA) to report any cases where no diagnosis is found. These cases are referred to DES/DDD Central Office. The Medical Eligibility Specialist must document their efforts to obtain the diagnosis. If the support coordinator gives a valid reason for delay in obtaining the diagnosis that indicates a long delay, such as a delay in the child starting school and thus receiving a school psychological evaluation, the PAS reassessment may be completed without the diagnosis and the reasons explained. On the next reassessment, attempts must be made again to obtain the DD qualifying diagnosis. ALTCS Eligibility Administration will communicate with DES/DDD Administration when the DD diagnosis cannot be obtained.

A.

The DD status dates entered in ACE must coincide with the PAS date to insure that the PAS is properly processed and that enrollment is correct. In general, EPD customers are enrolled with a county or a program contractor. DD customers are enrolled with DES/DDD, and customers who are pending DES/DDD determinations (Potential DDs) at the time of PAS completion are enrolled with DES/DDD.

B.

Changes in DD status may occur on a new application while the case is still pending, particularly if the customer is a Potential DD. When DES/DDD notifies the ALTCS office of the change in status enter the new DD status in ACE. If the PAS has already been entered but not completed, the new DD status may be applied retroactively back to the PAS date to ensure accurate processing and enrollment of the case.

C.

For changes in DD status on ongoing DD cases, the change is received from DES/DDD on an electronic Member Change Report (MCR), it should include, as an attachment, a copy of the notice that has been sent to the customer or family from DES/DDD. The PAS Assessor must allow for the customer's appeal period based on the date of that notice and communicate with the support coordinator to determine status of a potential appeal.

Once it is determined there is not an appeal of the DES/DDD discontinuance or the discontinuance has been upheld, the EPD PAS must be completed on paper and entered into Fortis. The DD status in ACE must not be changed to EPD until the outcome of the PAS and physician review if indicated, is known. The DD status change and the EPD PAS must be completed on the same day as the change in DD status affects enrollment. A change in DD status prior to completion of the EPD PAS would result in enrollment with an EPD program contractor even though the PAS eligibility has not been determined. The same is true for the rare case that changes from EPD to DD.

D.

It is also important to note that even though a customer may have been eligible for years as a DD, the first assessment as Not DD is treated like an initial in regards to enrollment and transitional program eligibility is not available. The same would be true going from EPD to DD. The PAS in ACE is entered as a reassessment.

A.

The PAS instrument for the elderly and physically disabled includes four major categories: intake information, functional assessment, emotional and cognitive functioning and medical assessment.

1.

The intake information category collects demographic information, the source of information and personal contacts information (entered in the PAS summary) and additional information which includes the customer's height and weight, acute care status, and ventilator status.

2.

The functional assessment category collects information about the customer's:

a.

Activities of daily living;

b.

Communication and sensory abilities; and

c.

Continence.

3.

The emotional and cognitive functioning category collects information on the customer's:

a.

Orientation; and

b.

Behavior.

4.

The medical assessment category collects information on the customer's:

a.

Medical conditions and their impact on the customer's ability to independently perform activities of daily living and whether such conditions require medical or nursing treatments;

b.

Medications, treatments, allergies and diet;

c.

Specific services and treatments that the customer receives or needs and the frequency of those services and treatments; and

d.

PAS summary.

B.

The responses selected by the Medical Eligibility Specialist in ACE calculate three scores: a functional score, a medical score and a total score, and compare to the established thresholds (Appendix 10A, the EPD PAS manual).

There are four age-specific PAS tools for customers with developmental disabilities and all children less than six years old. The tools are: 0-2; 3-5; 6-11; and 12+.

A.

The PAS instrument for customers with developmental disabilities includes three major categories: intake information, functional assessment and medical assessment.

1.

The intake information category (entered into PAS summary) collects demographic information, source of information personal contacts, and additional information that includes height and weight, measurements at birth, acute care status, and ventilator status.

2.

The functional assessment category collects information on the customer's:

a.

Developmental growth for children less than six years of age;

b.

Motor and independent living skills;

c.

Communication and cognitive functioning; and

d.

Behaviors.

3.

The medical assessment category collects information on the customer's:

a.

Medical conditions;

b.

Specific services and treatments that the customer receives or needs and the frequency of those services and treatments;

c.

Medications and treatments;

d.

Medical stability in terms of hospitalizations, caregiver training and special diet;

e.

Sensory functions; and

f.

PAS summary.

B.

The responses selected by the Medical Eligibility Specialist in ACE, calculate three scores, a functional score, a medical score, and a total score and compare to the established threshold. (See Appendix 10B, the DD PAS manual).

C.

The Medical Eligibility Specialist must pay close attention to the age of the customer less than 12 years of age. If the customer is approaching a birthday or an age milestone as indicated on the 0-2 PAS, the PAS may need to be delayed until after the birthday or other age milestone in order to ensure an accurate eligibility determination. For example, if the customer is 5 months old, 8 months old, 11 months old, 17 months old or is approaching their 3^rd, 6^th or 12^th birthday, the PAS should be conducted after they reach the next age milestone, if at all possible. The assessor must verify age and discuss with their supervisor on these cases. In most cases the PAS should not be completed until after the birthday or other age milestone.

A.

In order to be PAS eligible, customers must require care equal to that provided in a NF or ICF-MR. Customers who are hospitalized may not meet this requirement if, at the time of the PAS, they require a higher (acute) level of care. Process customers who apply for ALTCS and who are in hospitals or intensive rehabilitation facilities as follows:

1.

When the referral is received, check to see if the customer is ready for discharge within seven days. If the customer is ready for discharge, complete the PAS within two working days. It is important to make immediate contact with the hospital nursing or social service personnel involved in the discharge planning of the hospitalized customer and fully document the details including dates and names.

2.

If there is no discharge date but one is anticipated before or soon after the PAS due date, hold the referral until there is a discharge date and complete the PAS as soon as the discharge date is known.

3.

If there is no anticipated discharge date within 14 calendar days after the PAS due date, the PAS is completed as Acute Care, ALTCS ineligible. This should be thoroughly documented in the summary and the box indicating "currently hospitalized/rehab" on the DD or EPD information tab in ACE should be checked. When the next box "Imminent discharge from acute care facility" is not checked, the PAS will be determined "acute". In rare cases no further PAS information will be completed. The Medical Eligibility Specialist must discuss these cases with a supervisor before proceeding and fully document the reason there is no discharge date for this customer and the dates and names of the hospital staff providing this information.

B.

The Financial Eligibility Specialist cannot complete an application as eligible while the customer is hospitalized or in intensive rehabilitation. Medical and Financial Eligibility Specialists must work together closely on these cases to insure appropriate eligibility determinations.

C.

If a customer is hospitalized after the PAS has been completed, but before the case has been completed by the Financial Eligibility Specialist and discharge is not imminent, change the PAS in ACE to reflect the customer's acute status and document the date and reason for the change.

A.

A customer who is ventilator dependent is medically dependent upon a mechanical ventilator for life support at least six hours per day and has been dependent on ventilator support for at least 30 consecutive days.

B.

A registered nurse conducts the PAS. In addition to completing the PAS, the registered nurse must determine if the customer meets the ventilator dependent criteria and if so, complete the Ventilator Dependent Eligibility Determination Worksheet in ACE. Send notification via e-mail to the PAS QC unit in the Division of Member Services, ALTCS Eligibility Administration (AEA).

C.

Ventilator Dependent status impacts enrollment and capitation for Program Contractors, and it can generally only be changed through a PAS reassessment. If there is change in ventilator status, the Ventilator Dependent Coordinator will be notified by the Program Contractor sends a Member Change Report for to the Ventilator Dependent Program Coordinator who requests a reassessment from the Medical Eligibility Specialist. The Medical Eligibility Specialist completes the reassessment as soon as possible from the date of notification by the Ventilator Dependent Coordinator. In some cases the Ventilator Dependent Program Coordinator will request a Ventilator Dependent Eligibility Determination Worksheet be completed without a PAS.

Sometimes an initial PAS must be completed after the customer has died to determine if the customer would have been eligible prior to death. A deceased customer must have resided in a NF or an ICF-MR for at least one day during the application month for a PAS to be completed.

To determine whether customers who are not applying for ALTCS are at risk of institutionalization and require care equal to that provided in a NF or ICF-MR complete a private request PAS. These customers are assessed upon request and completed without a charge to the customer. The Private Request PAS is processed through Eligibility Review (see MS 1017), if indicated. A face-to-face assessment must be conducted to be considered a Private Request PAS and to be entered into ACE.

A.

A level of care is calculated and assigned by the ACE system as a secondary outcome of eligibility. (Appendix 10A (the EPD PAS instructions) or Appendix 10B (the DD PAS instructions).

B.

Before closing PAS on a fee-for-service case, the Medical Eligibility Specialist should briefly review the PAS to determine if the system assigned level of care is appropriate. The guidelines in MS 1015.1 should be used along with Appendix A4 of Appendix 10A, the EPD PAS instructions.

C.

If the system calculated level of care does not appear to be appropriate, and it appears that the level of care should be higher or lower than that assigned by the system, the PAS should not be closed until discussed with a supervisor.

D.

The assessor should document in comments, clearly identifying why the level of care should be changed. This explanation should contain objective facts, such as specific treatments the customer requires. The assessor should then submit the documentation to the branch or regional manager for review. If the branch or regional manager feels the level of care should be changed, he or she shall do so, using the administrative override process.

E.

If the branch or regional manager does not feel the level of care should be changed, he or she should return the documentation to the assessor with an explanation.

F.

Any time the branch or regional manager is unsure of the appropriate level of care to assign, the PAS should be discussed with the ALTCS Eligibility Manager in AEA.

G.

A fee-for-service case manager may ask for a level of care review at any time there is significant change in the customer's condition or if they disagree with the assigned level of care. For disagreements with the assigned level of care, the above process must be used. For changes in the customer's condition, a PAS reassessment may be required. The assessor must discuss these requests with the branch or regional manager who will discuss with the ALTCS Eligibility Manager as needed.

A.

LEVEL I (ICF) (Eligibility Thresholds)

1.

Total Score > 60 or

2.

Group 1 and Medical Score > 13 and Functional Score > 30; or

3.

Group 2 and Functional Score > 30 and score of > 5 on orientation or any behavior item scored 2 or more.

B.

LEVEL II (SNF-I)

Must meet Level I criteria and:

1.

Feeding assistance (tube or parental); or

2.

Any two or more respiratory services; or

3.

ADL weighted score > 75; or

4.

ADL weighted score > 63 and continence weighted score > 2; or

5.

Functional score > 81 or ADL weighted score > 63 and orientation/emotional/cognitive behavior weighted score > 20; or

6.

Medical score > 20.

C.

LEVEL III (SNF-II)

1.

Group I and total score > 104 and Functional score > 86 and Medical score > 17; or

2.

Group I and Functional score 86 - 99.99 and two of the services listed in 5. below; or

3.

Group I and Functional score > 100 and one service listed in 5. below; or

4.

Group II and Functional score 100 - 119.99 and two services listed in 5. below; or

5.

Group II and Functional score > 120 and one service listed below.