F-01012 - Reimbursement Request For A Pasarr Level I Screen
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1DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Health Care Access and Accountability
F-01012 (07/12)
FORWARDHEALTH
REIMBURSEMENT REQUEST FOR A PASARR LEVEL I SCREEN
The information on this reimbursement request is required to ensure that Medicaid-certified long term care facilities, nursing facilities
(NFs), are only paid for Level l Screens that are required under 42 CFR s. 483.104. On February 1, 1997, new reimbursement
guidelines were implemented by Wisconsin Medicaid based on this federal regulation. Effective February 1, 1997, only Level l Screens
1
performed on residents who meet the definition of a new admission
are reimbursable.
2
Nursing facilities are not required to perform a new Level l Screen on residents who are returning from a hospital stay, readmission
, or
3
interfacility transfer
. If an NF elects to perform a new Level I Screen for a readmission or interfacility transfer, the NF should not seek
reimbursement for it.
Submit this completed form by mail to ForwardHealth, Claims and Adjustments, 313 Blettner Boulevard, Madison, WI 53784.
Instructions: Type or print clearly. Before completing this form, read the Reimbursement Request for a PASARR Level I Screen
Completion Instructions, F-01012A. The use of this form is mandatory; use an exact copy of this form.
Name — NF (Practice Location Name, not Corporate Name)
POP ID (Required)
National Provider Identifier — NF
Last Name — Resident
First Name — Resident
Social Security Number — Resident
Screen Date
Admission Date
/
/
/
/
Preadmission History — Where was this resident prior to his or her admission to this NF?
Check only one box. Multiple responses will result in a denial of the reimbursement request.
A.
A private residence.
B.
Another Medicaid-certified NF.
1
C. Hospital — admitted to the hospital from a private residence
.
2
D. Hospital — readmission
.
3
E.
Hospital — interfacility transfer
.
CERTIFICATION
This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of this
reimbursement request is from federal and state funds, and that any false claims, statements, documents, or concealment of material
fact may be prosecuted under applicable federal or state laws.
Name and Telephone Number — NF Contact
SIGNATURE — Provider
Date Signed — Provider
1
New Admission — An individual is admitted to an NF from a private residence (e.g., private home, group home, or intermediate care
facility-mentally retarded [ICF-MR]) with or without an intervening hospital stay. If an individual transfers to an NF from a hospital, and
his or her residence prior to the hospital stay was a private residence, a Level I Screen is required.
2
Readmission — An individual is readmitted to an NF from a hospital to which he or she was transferred for the purpose of receiving
care. If the transferring NF considered the resident discharged from the NF during the time he or she was in the hospital, it is still
considered a readmission when that resident transfers back to the NF from the hospital. A new Level I Screen is not required.
If the resident is discharged to a private residence from the hospital but needs to return to the NF at a later time, that would be a “new
admission.” A new Level 1 Screen would be required.
3
Interfacility Transfer — An individual is transferred from one NF to another NF, with or without an intervening hospital stay. The
admitting NF is not required to perform a new Level I Screen.
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