Schedule 7 - Evaluation and Notice of Appeal Rights-Jane Doe.docx
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- Solicitation number
- S-0627 DCTS-17
- Issued by
- Wisconsin
About this file
This is a Schedule 7 evaluation form template for the Wisconsin Department of Health Services, Division of Mental Health and Substance Abuse Services, related to a Request for Bid (RFB No. S-0627 DCTS-17) for Preadmission Screening and Resident Review (PASRR) Level II Screens. The form serves as a test case documentation tool designed to evaluate vendor capability to make correct determinations regarding nursing facility admissions and resident placements for individuals with serious mental illness or intellectual/developmental disabilities. The document is a Microsoft fillable form that requires vendor completion based on clinical information provided in Appendix H, with the completed determinations and supporting rationales subject to sole judgment by the Department of Health Services. Incorrect determinations or unclear rationales provided by bidding vendors will result in bid disqualification. The form template is dated October 2008 (Form F-20854) and was released on April 29, 2013.
The Schedule 7 evaluation form presents two main decision pathways required under federal regulation 42 CFR 483.118: first, determining whether an individual can be admitted to or must remain in a nursing facility based on assessed need for nursing facility services; and second, determining the level of specialized services required, ranging from intensive continuous treatment programs for developmental disability or mental illness to specialized psychiatric rehabilitation services to no specialized services. The form includes mandatory appeal rights notifications with specific timeframes for appeals to the Division of Hearings and Appeals, including critical 10-day and 45-day deadlines, and notification of Medicaid payment implications contingent on appeal status. Vendors must provide clear, lay-term explanations of their determinations to support their clinical judgments.
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Schedule 7 – FOR JANE DOE
RFB Instructions: Complete this Schedule using the information provided in Appendix H – Clinical Example/Test Case-Jane 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 7 – FOR JANE 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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