Okla. Admin. Code § 317:35-19-2 - Nursing Facility (NF) program medical eligibility determination
The Oklahoma Human Services (OKDHS) area nurse or nurse designee, determines medical eligibility for NF services based on the OKDHS nurse's Uniform Comprehensive Assessment Tool (UCAT) assessment of the client's needed level of care, the outcome of the Level II Preadmission Screening and Resident Review (PASRR), when completed, and his or her professional judgment. The Oklahoma Health Care Authority (OHCA) Level of Care Evaluation Unit (LOCEU) makes some determinations when the PASRR is involved. Refer to Oklahoma Administrative Code (OAC) 317:35-19-7.1(3) for NF level of care medical eligibility requirements.
(1) When NF care services are requested prior
to admission, the same rules related to medical eligibility determination
identified in OAC
317:35-17-5 for ADvantage
services are followed.
(2) The
OKDHS nurse reviews the PASRR Level I in the OHCA system; completes the UCAT;
and enters the date OHCA received the PASRR Level I (LTC-300R) from the NF and
admission date to the NF; medical eligibility effective date and notes any
Level II PASRR results if available in the UCAT Part III. This information is
submitted to the OKDHS area nurse for medical eligibility
determination.
(4) When it is not possible to complete the
UCAT assessment prior to admission, the NF is responsible for notifying OKDHS
of the admission. Notification is mailed or faxed on OKDHS Form 08MA083E,
Notification Regarding Patient In A Nursing Facility, Intermediate Care
Facility for the Intellectually Disabled or Hospice, and Management Recipient
Funds to the local OKDHS county office. Upon receipt, the OKDHS county office
processes Forms 08MA083E and 08MA084E and completes and forwards the Form
08MA038E, Notice Regarding Financial Eligibility to the NF. Identified sections
of the UCAT reflecting the domains for meeting medical criteria are completed
for applicants residing in the NF at the time of assessment. The area nurse or
nurse designee, confirms the date of medical eligibility and records it in the
system. The facility is responsible for performing the PASRR Level I screen and
consulting with OHCA staff to determine when a need exists for a Level II
screen. The OKDHS nurse completes the assessment within fifteen-business
(15-business) days of PASRR clearance when the individual's needs are included
in an active OKDHS coded case. When the individual's needs are not included in
an active case, the assessment is completed within twenty-business
(20-business) days of PASRR clearance.
(5) The area nurse or nurse designee,
evaluates the PASRR Level I screen and the UCAT in consultation with the OKDHS
nurse when the completed LTC-300R and/or facility documentation shows a need
exists for a possible Level II screen. The area nurse or nurse designee
consults with OHCA staff as necessary.
(6) The area nurse or nurse designee,
evaluates the UCAT, to determine if the applicant meets the medical eligibility
criteria for NF level of care. Individuals may be medically-certified for NF
level of care for various lengths of time depending on the client's needs. The
area nurse or nurse designee, enters the medical eligibility decision and, when
required, the medical certification review date into the electronic system
within ten-business (10-business) days. A medical eligibility redetermination
is not required when a client is discharged from the NF for a period not to
exceed ninety-calendar (90-calendar) days and the original certification is
current.
(7) When the OKDHS nurse
recommends NF level of care and the client is determined by the area nurse or
nurse designee, not to be medically eligible for NF level of care, the OKDHS
nurse can submit additional information to the area nurse or nurse designee.
When necessary, a visit by the OKDHS nurse to obtain additional information is
initiated at the recommendation of the area nurse or nurse designee.
(8) Categorical relationship must be
established for determination of eligibility for NF services. When categorical
relationship to disability has not been established, the worker submits the
same information, per OAC 317:35-5- 4(2), to the LOCEU to request a
determination of eligibility for categorical relationship. LOCEU renders a
decision on categorical relationship to the disabled applicant using the Social
Security Administration (SSA) definition. A follow-up with the SSA by the OKDHS
worker is required to ensure the SSA disability decision agrees with the LOCEU
decision.
Notes
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