Schedule 6 - Evaluation and Notice of Appeal Rights-John Doe.docx
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- Solicitation number
- S-0627 DCTS-17
- Issued by
- Wisconsin
About this file
This is a Schedule 6 form—an evaluation and notice of appeal rights document—issued by the Wisconsin Department of Health Services, Division of Mental Health and Substance Abuse Services, in connection with a Request for Bid (RFB No. S-0627 DCTS-17) for Preadmission Screening and Resident Review (PASRR) Level II Screens. The document serves as a test case template for vendor bid evaluation, using a fictional client named John Doe to assess vendors' ability to make correct determinations regarding nursing facility admission eligibility and specialized service requirements. The form is designed to be completed by vendors to demonstrate their understanding of federal PASRR regulations (42 CFR 483.118, 483.128, 483.134, and 483.136) and their capacity to communicate complex determinations in lay terms. Vendors must complete this schedule based on information provided in Appendix G—Clinical Example/Test Case, with incorrect determinations and unclear rationales serving as grounds for bid disqualification. The document is a Microsoft fillable form with checkbox options and open-text fields for vendor responses.
The form communicates federal requirements and appeal rights to prospective and current nursing home residents, outlining five primary determination scenarios regarding nursing facility admission or continued stay eligibility and three scenarios regarding specialized service needs. Residents are informed of their 45-day appeal window to the Division of Hearings and Appeals and, for Medicaid recipients facing discharge determinations, a 10-day expedited appeal window to maintain payment continuity. The form requires signatures from both the PASRR team member providing the summary and the client or guardian, with additional approvals potentially required from county departments and the Division of Quality Assurance before admission. This document functions as both a vendor evaluation tool and a legally mandated patient notification instrument under federal regulations.
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Text version
Schedule 6 – FOR JOHN DOE
RFB Instructions: Complete this Schedule using the information provided in Appendix G – Clinical Example/Test Case-John Doe. This is a test of Vendor’s ability to make correct determinations and provide a supporting rationale that is understandably written in lay terms. DHS shall be the sole judge of correct determinations and understandable rationales. Incorrect determinations and unclear rationales will be grounds for Vendor bid disqualification.
Note: This form is a Microsoft fillable form. If you left click on a box, the box will be marked with an X. The highlighted text fields are unlimited in length.
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN
Division of Mental Health and Substance Abuse Services F-20854 (10/2008)
Preadmission Screening and Resident Review (PASRR) Level II Screens
RFB 3037-DMHSAS-CB
Release Date 04/29/2013 RFB No. S-0627 DCTS-17
LEVEL II PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR)
EVALUATION SUMMARY AND NOTICE OF APPEAL RIGHTS
I. A member of the Preadmission Screen and Resident Review (PASRR) Area Evaluation Team checked the box below that applies and explained to me the results of my PASRR Level II screen and whether or not I can be admitted or stay in a nursing facility:
| |_| | a) | The federal regulation, 42 CFR 483.118, says that I cannot be admitted to a nursing facility because it was decided that I do not need the services of a nursing facility. If I want to appeal this decision, the Division of Hearings and Appeals must receive my letter within 45 days of the day I receive this notice. |
| |_| | b) | The federal regulation, 42 CFR 483.118, says that I cannot stay in a nursing facility because it was decided that I do not need the services of a nursing facility. If I want to appeal this decision, the Division of Hearings and Appeals must receive my letter within 45 days of the day I receive this notice. See the note below for time requirements for Medicaid payment. |
| |_| | c) | The federal regulation, 42 CFR 483.118, says that I cannot stay in a nursing facility because I have been in a nursing facility for less than 2½ years and it was decided that I do not need the services of a nursing facility, although I do need specialized services (see page 2). If I want to appeal this decision, the Division of Hearings and Appeals must receive my letter within 45 days of the day I receive this notice. See the note below for time requirements for Medicaid payment. |
NOTE: The impact of a determination for b) or c) depends of whether or not and when I appeal this determination:
| 1) | If I receive Medicaid and choose not to appeal this decision, then the Medicaid program will stop paying for my stay in the nursing facility in 10 days from the day I receive this notice. | |
| 2) | If I receive Medicaid and I want the Medicaid program to continue paying for my stay in the nursing facility, the Division of Hearings and Appeals must receive my appeal letter within 10 days from the day I receive this notice. If I appeal this decision and the hearing officer decides I do not need the services of a nursing facility, then the Medicaid program will stop paying for my stay in the nursing facility as of the date of the hearing officer’s decision. If I appeal this decision and the hearing officer decides I do need the services of a nursing facility, then I may stay in the nursing facility and the Medicaid program will continue to pay for my stay. | |
| 3) | If I receive Medicaid and the Division of Hearings and Appeals receives my appeal letter after 10 days after I receive this notice, then Medicaid payment for my stay in the nursing facility will stop. If the hearing officer decides I do need the services of a nursing facility, then I may stay in the nursing facility and the Medicaid program will pay for my stay, including the time during the appeal process. | |
| |_| | d) | The federal regulation, 42 CFR 483.118, says that I can stay in a nursing facility if I want to stay, even though it was decided that I do not need the services of a nursing facility, because I have been in a nursing facility for more than 2½ years and because it was decided that I do need specialized services. |
| |_| | e) | The federal regulation, 42 CFR 483.118, says that I can be admitted or stay in a nursing facility, because it was decided that I need the services of a nursing facility. |
This decision was based primarily on the following:
[Enter your response here]
SIGNATURE – PASRR Team Member Providing Summary (Name of Vendor)
| Date Signed |
Schedule 6 – FOR JOHN DOE page 2 – LEVEL II PASRR EVALUATION SUMMARY AND NOTICE OF APPEAL RIGHTS
II. A member of the Preadmission Screen and Resident Review (PASRR) Area Evaluation Team checked the box below that applies and explained to me how the results of my PASRR Level II screen will affect the care and treatment I receive in a nursing facility (if I can be admitted or stay in a nursing facility; see page 1 of this form):
| |_| | a) | Based on the federal regulations, at 42 CFR 483.134 and 483.136, it was determined that I need an intensive, continuous treatment program called specialized services for my developmental disability or my mental illness. If I want to appeal this decision, the Division of Hearings Appeals must receive my appeal letter within 45 days of the day I receive this notice. |
| |_| | b) | Based on the federal regulations, at 42 CFR 483.134 and 483.136, it was determined that I need services of a lesser intensity than specialized services called specialized psychiatric rehabilitation services for my mental illness. If I want to appeal this decision, the Division of Hearings Appeals must receive my appeal letter within 45 days of the day I receive this notice. |
| |_| | c) | Based on the federal regulations, at 42 CFR 483.134 and 483.136, it was determined that I do not need specialized services or specialized psychiatric rehabilitation services for my developmental disability or my mental illness. If I want to appeal this decision, the Division of Hearings Appeals must receive my appeal letter within 45 days of the day I receive this notice. |
This decision was based primarily on the following:
[Enter your response here]
III. If I think either of the PASRR decisions are wrong, then I can appeal these decisions to the:
Division of Hearings and Appeals 5505 University Avenue, Suite 201 P.O. Box 7875 Madison, WI 53707-7851
· The information in this form is required, by federal regulations at 42 CFR 483.128(j)-(l), to be presented to persons who receive a PASRR Level II screen. If this notice was mailed, then sign and return one copy to [the PASRR contract agency].
· If I want to appeal, I must include a copy of this notice with a letter that says I want to appeal.
· I was told that I may choose to represent myself at the hearing or I may choose to be represented, at my cost, by an attorney, a relative, a friend, an advocate or other spokesperson. I was told that my county department of social services will give me the names of organizations that provide free legal assistance in my area of the state.
· I have received an explanation and a copy of this Evaluation Summary and Notice of Appeal Rights.
SIGNATURE – PASRR Team Member Providing Summary (Name of Vendor)
| Date Signed |
| SIGNATURE – Client or Guardian/Health Care Agent (if applicable) |
| PRINT – Client’s Name |
| Date Signed |
Note: Additional approvals from other parties (the county department of human services/community programs, the county court, and the Division of Quality Assurance (DQA) may be necessary before you can be admitted to a nursing facility.
RFB No. S-0627 DCTS-17
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