*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: August 1, 2009 |
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23.25 - Communication Forms for Long-Term Care (LTC) Cases |
Archived: June 1, 2016 |
This section describes the forms used to facilitate communication with lead agency case managers and long-term care facilities (LTCF). Timely communication is important so clients can access the services they need as soon as possible.
Keep copies of communication forms that are used in the case file to document the information exchanged.
Lead Agency Case Manager/Worker Communication Form (DHS-5181).
Lead Agency Case Manager Responsibilities.
Long-Term Care/County Communication Form (DHS-3050).
Physician Certification (DHS-1503).
Lead Agency Case Manager/Worker Communication Form
The Lead Agency Case Manager/Worker Communication Form (DHS-5181) is a mandatory form for communication between lead agency case managers and workers who determine eligibility for MA payment of long-term care (LTC) services. The form helps ensure that an eligibility determination is made as quickly as possible when an MA applicant or enrollee requests MA payment of LTC services through a Home and Community-Based Services (HCBS) waiver program. In addition, it helps to communicate changes about an MA enrollee who is receiving waiver services.
Generally, lead agency case managers initiate the DHS-5181 following a Long-Term Care Consultation (LTCC) to share information about:
l MA applicants or enrollees who request services through a HCBS waiver.
l MA enrollees who are receiving services through a HCBS waiver and experience a change in circumstances; for example, move to an LTCF, exit the HCBS waiver, or move to a different HCBS waiver program.
Note: Send the DHS-5181 via fax, interoffice mail or through the U.S. mail only. Secure internet e-mail cannot be guaranteed; therefore, do not share this private information through e-mail.
Lead Agency Case Manager Responsibilities
Part 1 of the DHS-5181 includes the following sections:
n Section A - Contact Information.
Provides the lead agency case manager’s information and identifies the client.
n Section B - Waiver Program Status.
Provides information about the client’s home and community-based waiver program status.
n Section C - Comments.
Used to provide or request additional information.
The lead agency case manager must complete all sections of Part 1and send the DHS-5181 via fax, interoffice mail or U.S. mail to the county or tribal agency immediately after:
1. completing the Long-Term Care Consultation (LTCC).
2. becoming aware of a change in the MA applicant’s or enrollee’s situation, including:
m address change, including a move to an LTCF, when known.
m exit from a home and community-based waiver program, and the reason why.
m change in which home and community-based waiver program the MA enrollee is receiving services.
m enrollment in or disenrollment from a managed care plan, when known.
m other changes.
Note: The lead agency case manager must complete all applicable information, including the screening date and anticipated start date of waiver services whenever applicable.
The lead agency case manager must assist the client with completing the Request for Payment of Long-Term Care Services (DHS-3543) when requested by the client or the client’s authorized representative, or when the worker sends a DHS-5181, Part 2 indicating that the client has not returned a required DHS-3543.
Part 2 of the DHS-5181 includes the following sections:
n Section D - Contact Information.
Provides the worker’s contact information and identifies the client.
n Section E - Medical Assistance (MA) Status.
Provides information about the client’s MA eligibility status.
n Section F - Comments.
Used to provide or request additional information.
Workers must complete all sections of Part 2 and send the DHS-5181 via fax, interoffice mail or U.S. mail to the lead agency case manager:
n within 10 working days after receiving the DHS-5181 with Part 1 completed if eligibility for MA payment of LTC services has not yet been determined. Indicate on the form if the determination is still pending or if the MA enrollee has not returned the DHS-3543. Keep a copy of the completed form in the case file.
Note: The Lead Agency Case Manager must follow up with the client when the reason the MA eligibility determination has not been made is because the MA enrollee has not returned the DHS-3543.
n 45 days after first receiving the completed Part 1 if eligibility can still not be determined.
n immediately upon approval or denial of a client’s request for MA payment of LTC services.
n immediately after processing a change, including:
m Address change.
m Termination of eligibility for MA or MA payment of LTC services.
m Death.
m Move to a LTCF.
m Other.
Evaluate eligibility for MA payment of LTC services if an MA enrollee is found to be open on a HCBS waiver program in MMIS, but eligibility for MA payment of LTC services was not determined.
n Send the DHS-3543 to the enrollee.
n Send the DHS-5181 to the lead agency case manager after completing Part 2.
Make a referral to the county LTCC team when:
n a client files a request for MA payment of LTC services by completing a Minnesota Health Care Programs Application for Payment of Long-Term Care Services (DHS-3531); and
n a case manager has not provided a Lead Agency Case Manager/Worker Communication Form (DHS-5181) that indicates the client meets the institutional level of need requirement.
Long-Term Care/County Communication Form
The Long-Term Care/County Communication Form (DHS-3050) is used to aid communication between an LTCF and workers who determine eligibility for LTC services.
The DHS-3050 includes a release of information. The LTC client or the authorized representative must sign and date this form to allow the release of certain information to the facility. Do not release information to an LTCF regarding the reason for an approval, denial or closure unless a release of information is on file. Require a signed release when a facility requests information not available on the Eligibility Verification System (EVS). The release expires one year from the signed date.
The DHS-3050 can be used to request the following information from an LTCF:
l A DHS-1503 to be completed by the LTCF.
l Admission or discharge date information.
l Cost of care amounts.
l Third party payment information, including Medicare.
l Asset information in the form of a resident fund.
l Other information as needed.
Use the DHS-3050 to share or obtain information about:
l MA applicants who request services in an LTCF.
l MA enrollees who request services in an LTCF.
l MA applicants or enrollees who are applying for or receiving services in an LTCF and experience a change, for example:
n LTC coverage was denied, approved or closed.
n non-LTC coverage was approved.
n client was enrolled in a PMAP.
l Completion of the PAS as found on the Physician Certification (DHS-1503).
l LTCF information needed, such as admit or discharge dates, daily facility rates, or Medicare payments made toward the cost of care.
l A change in an enrollee’s monthly recipient amount.
l A resident’s fund balance.
l Other information needed.
Note: Send the DHS-3050 via fax, interoffice mail or through the U.S. mail only. Secure internet e-mail cannot be guaranteed; therefore, do not share this private information through e-mail.
The Physician Certification (DHS-1503) is a mandatory form that is completed by the LTCF and sent to the county. Its purpose is to certify that the person being admitted to the LTCF has had a PAS to determine the need for a nursing facility level of care.
The LTCF must complete the DHS-1503 within 72 hours (not including weekends or holidays) after the MA applicant or enrollee is admitted to the facility, providing the following information:
l Facility name and provider number.
l Physician name.
l Date of Admission.
l Anticipated Discharge Date.
l Recipient name.
l Reason for Admission (both the primary and if there is a secondary diagnosis).
l Date of the PAS for a skilled nursing facility/nursing facility (SNF/NF) or reason if it is not required.
l Screening for an intermediate care facility for the developmentally disabled (known as ICF/DD).
l Admission Information for Date of First Admission.
n Level of Care.
n Length of Stay.
n Admitted From.
l Physician Signature.
When the county agency receives the DHS-1503, determine eligibility for MA payment of LTC services, complete the local county agency information on the DHS-1503 and return the form to the LTCF.