Top Questions asked TMHP by Nursing Facilities
As of December 8, 2008
1. How do I complete a Purpose Code E on an MDS?
Response: A Minimum Data Set (MDS) can only be processed for one of the following reasons (purposes) per assessment:
The MDS can either:
a. create/extend the cycle for the Resource Utilization Group (RUG)
OR
b. fill a prior gap in the RUG: this requires a Purpose Code M or a Purpose Code (PC) E
If an MDS is needed to fill a prior time period, a separate MDS must be submitted and the Long Term Care Medicaid Information (LTCMI) must be completed with a Purpose Code E or a Purpose Code M. This additional MDS should be submitted with the Reason for Assessment field (AA8a) coded with the value that would have been appropriate for the missed timeframe.
Note that Purpose Code E’s and M’s can only be submitted on an Admission assessment (01), an Annual assessment (02) or a Quarterly assessment (05). This assessment will not extend the Payment RUG beyond the begin date of the current RUG. It is only used for a prior timeframe.
A Purpose Code M can only fill a gap for which retroactive eligibility has been established. Payment is made at the full calculated RUG rate.
Any gap that is not covered by retroactive eligibility must be filled by a Purpose Code E; payment will be made at the default RUG rate of PCE.
2. Can you tell me whether this/these client/s have approved medical necessity?
Response: Nursing Facilities (NFs) with this request will be provided the most recent information once they have given TMHP the necessary provider and client verifying information. NFs should also check the status of their form using Form Status Inquiry, displaying the form and scrolling to the bottom of any page to view the historical steps the form has taken. The last status will indicate what state the form is in at the time the form is displayed.
3. Why am I receiving this error on my form OR what does the “Provider Action Required” status on my form mean?
Response: The following provider training materials are used to guide the NF through determining what action is required to process their form(s):
http://www.dads.state.tx.us/providers/tilestorugs/nfproviderworkflow.pdf
4. Why is my MDS information not updated on the MESAV?
Response: TMHP will review the Portal status of the MDS in question.
· If the form is in a validation status pending for ID, ME or AI, the NF will be referred to the local eligibility worker.
· If the status is provider action required, the NF is informed that the facility is responsible for addressing the problem.
· If the status is submitted to the manual workflow and it has been greater than 10 business days since the action occurred, the NF is directed to contact Provider Claims Services at 512/438-2200, Option 1, to have the MESAV updated.
5. Do I need to complete the LTCMI on this client?
Response: NFs are directed to complete the LTCMI when seeking full Medicaid reimbursement (when a resident is moving to full Medicaid or continuation of Medicaid payment). The LTCMI is not required on Medicare residents or co-insurance; however, it is recommended if any of the timeframes could involve Medicaid.
6. I have a Form 3618/3619 on file but the MDS will not let me submit an LTCMI because it says there is no 3618/3619 on file.
Response: TMHP researches all forms per resident/contract number to help determine if there is a missing admit/discharge form.
· If TMHP determines that an admit/discharge is missing, the NF is directed to submit the appropriate missing form.
· If it appears that all forms are present and the NF continues to receive an error, TMHP will research to determine the reason the LTCMI cannot be submitted.
Providers can reach TMHP toll-free (outside Austin) at 1-800-626-4117 or 1-800-727-5436, or through the Austin local telephone number at 1-512-335-4729.
7. When do I complete an off-cycle MDS?
Response: The NF should refer to the MDS-RAI (Resident Assessment Instrument) manual for complete instructions regarding when to complete an off-cycle MDS. An off-cycle MDS may need to be submitted for the purpose of submitting an MDS PC E or PC M (only used for retroactive eligibility). If a PC E or PC M is completed on an MDS that had been used for Medicaid payments it inactivates the service dates previously established by the MDS. This is why a separate MDS must be submitted for the PC E/PC M.