Submit This Form Within 24 Hours of Admission, Discharge, and Change in Status Or Case Mix

/ Nursing Home Communication Form / SCHA # 2297 (1/2016)
Submit Fax Request to:
888-889-7822 (Fax) / Or Mail to:
Mayo Clinic Health Solutions
PO Box 211698
Eagan, MN 55121 / SCHA Provider Services
800-995-4543 (Phone)

Submit this form within 24 hours of admission, discharge, and change in status or Case Mix.

Member Name: / Date:
Member ID: / Member DOB:
Product Type: / MSC+
SeniorCare Complete
AbilityCare / Date of Initial Admission:
Admit Diagnosis/ICD10
Facility Name: / Provider NPI #:
Facility Contact: / County:
Facility Phone #: / Facility Fax #:
Reason Code:
1. Initial Admission-skilled / 6. Discharge Home / 11. Bed Hold Days – Medical
2. Initial Admission – non-skilled / 7. Discharge to Hospital / 12. Bed Hold Days – Therapeutic
3. Readmission / 8. Member expired / 13. Bed Hold Days – Hospice
4. End of Benefit Days / 9. Discharge to another SNF / **14. ISD – Intensive Service Days
5. Change to skilled services / 10. Discharge Part A, remain in same SNF / 15. Other (Identify in “Notes”)
Admission (A)
Change (C)
Discharge (D) / Effective Date / Reason Code / Inpatient Admission? / # of Medicare “A” Days Used / Medicare/State Case Mix RUG Code (e.g. SE2, RAA) / # of Non-Skilled days Used (180 MSHO only) / NOMNC given?
Y/N / # of days / Y/N / Date
Notes:

**For SENIORCARE COMPLETE and ABILITYCARE members: Prior authorization of Intensive Service Days (ISD) is required.

FOR HEALTH PLAN USE ONLY / End of Health Plan Liability. Health Plan faxes form to DHS at 651-431-7426 and copies facility / Y/N / Initial / Date
Date Received / # of qualifying days / Return to Facility Date / Initial

All fields are required. If not completed, the Notification could be considered incomplete and may not be entered into the claim payment system. This will result in delays to claims processing.

This form MUST be submitted within 24 hours of admission for claims payment.

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MSC+, SeniorCare Complete, AbilityCare: Check appropriate box

General Information: (Member name, ID name, DOB, Facility Name, Contact Person, Facility Contact Phone number, Provider NPI #, County that the Nursing Home is located, Nursing Home fax number) It is important to include your fax number and phone number so if we have questions we can contact you in a timely manner.

Admission information: Date of Initial Admission – when the member was first admitted to that nursing home.

Admitting Diagnosis: Please use ICD-10 code and description.

Admission (A), Change (C), Discharge (D):

Admission (A) is the day the member was admitted, transferred, readmitted to your facility.
Change (C) is when the member has had a change in medical condition resulting in change in the Medicare or State Case Mix RUG category. The member may be changing from skilled care to non-skilled care or vice versa.
Discharge (D) is used if the member went home, expired, transferred to the hospital or to another skilled nursing facility.

Effective Date: Date of the Admission, Change or Discharge.

Reason Code: List the reason why the member’s current stay is being changed in some way. SCHA needs to track the Medicare, Medicaid, bed hold, and Hospice days while the member is in the SNF.

**Intensive Service Days must be prior authorized by Mayo Clinic Health Solutions. ISD days allow the SNF to increase the member’s level of care in order to prevent hospitalization.

Inpatient Admission: Is there an inpatient admission associated with this admission, or change in case mix? If so, how many days was the member inpatient?

# of Medicare “A” days used: Document the number of Medicare skilled days used since admission or the during the current skilled episode.

Medicare/State Case Mix RUG Code: Document the associated level of care for the admission or change. Medicare RUG codes for skilled days and State Case Mix codes for Medicaid days. We understand that on admission, the RUG code will be an estimate.

# of non-skilled days used: Document the number of Medicaid days used (this is in conjunction with the Medicare days). For example, if the member uses 100 skilled days and then becomes non-skilled care, the 100 Medicare days would come out of the 180 days. SCHA may continue to pay for 80 more non-skilled days to the benefit max of 180 days. DHS has liability for SeniorCare Complete nursing facility that were on PMAP before the passive enrollment on 01/01/06. SCHA would have liability for the SNF days on SeniorCare Complete.

Notice of Medicare Non-Coverage (NOMNC): With the documented change in skill or coverage, did you facility issue a NOMNC to the member? Date the NOMNC was given to the member?

If you have any questions, contact Provider Services at 1-800-995-4543.

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