0815.020.00 Initial Assessment and Medical Certification

All applicants or participants requesting vendor benefits must be medically certified by the Department of Health and Senior Services, Division of Senior and Disability Services for the appropriate level of care. The attending physician or facility completes the form DA-124A/B Initial Assessment - Social and Medical form and sends it along with a copy of the DA-124C Level One Nursing Facility Pre-Admission Screening for Psychiatric Illness/Intellectual Disability or Related Condition form to the Central Office Medical Review Unit (COMRU). The COMRU State Medical Consultant reviews the form and certifies the level of care.

• If the applicant or participant enters or wishes to enter a state psychiatric hospital, the level of care certification must be MHC.
• If the applicant or participant enters or wishes to enter a state institution for the developmentally disabled, the level of care certification must be IMR.
• If the applicant or participant enters or wishes to enter a MO HealthNet certified bed in a nursing facility, the level of care certification must be NF.

Exception: For a child under age 21 who is receiving inpatient psychiatric services, medical certification is obtained on form IM-71 (Certification of Need for Psychiatric Services). See Section 0815.055.00.

0815.020.05 Verification of Medical Certification

FSD must verify that the applicant or participant is medically certified by viewing the DA-124 Inquiry Report screen. The DA-124 Inquiry Report screen is accessed from the Facility Placement Detail screen (FACPLACE or FMJ4) in FAMIS (F14=I124) or from the screen IMNF. Print a copy of the DA-124 Inquiry Report screen and file in the case record because the results are only available on the DA-124 Inquiry Report screen for 16 months. Enter the determination on the Facility and Placement Information Details (FACPLACE or FMJ4) screen in the DA-124A/B Level of Care field.  See the FAMIS User Guide FACILITY AND PLACEMENT INFORMATION DETAILS.

NOTE: FAMIS will not display any outstanding verification for Level of Care on the Outstanding Verification screen (OUTVERF or FM3M). Level of care is not information the claimant can supply. Eligibility Specialists must set a Reminder in FAMIS to check for the Level of Care Determination on the DA-124 Inquiry Report screen. Set Reminders in FAMIS to track pending actions:

• 30 days from the date of entry into the facility to determine if the DA-124 certification is available, if not;
• at 10 day intervals check the IMNF screen until the information is available on the I124 screen.

Exception: For a child under age 21 who is receiving inpatient psychiatric services, FSD must obtain a copy of the IM-71 Certification of Need for Psychiatric Services form. See Section 0815.055.00.

0815.020.10 Claimant Not Medically Certified

If COMRU determines that the applicant or participant is not medically certified for NF, IMR or MHC level of care, (LOC = NONE):

1. Record a comment on Eligibility Unit Member Role screen (EUMEMROL) to explain the individual's ineligibility for vendor.
2. File a copy of the DA-124 Inquiry Report screen in the case record.
3. Enter the COMRU LOC determination on the Facility and Placement Information Details screen (FACPLACE or FMJ4) DA-124A/B Level of Care field, and record a comment.
4. Complete the eligibility determination (EDRES) for MHABD Spend down or Non-Spend down.
5. Authorize the actions to approve or reject the MHABD request.

If COMRU determines that the applicant or participant is not medically certified for NF, IMR or MHC level of care (LOC=SNC):

1. Record a comment on Eligibility Unit Member Role screen (EUMEMROL) to explain the individual's ineligibility for vendor.
2. File a copy of the DA-124 Inquiry Report screen in the case record.
3. Explore eligibility for a SNC cash grant if the claimant is in or will be moving to a non-MO HealthNet certified bed by updating entries on the Facility and Placement Information Details screen (FACPLACE or FMJ4) to facility type CGZ and type of bed SNF. Refer to the FAMIS User Guide Facility and Placement Information Details. Determine eligibility for SNC from the date of the request for MHABD vendor. Determine if the individual is qualified for Supplemental Nursing Care, using Section 0600.000.00.
4. If ineligible for a SNC cash grant, complete the eligibility determination (EDRES) for MHABD Spend down or Non-spend down.
5. Authorize the actions to approve or reject the MHABD request.

   NOTE:  Always review the Budget Summary screen prior to authorizing a case action in FAMIS. From the MHABD Action Authorization screen (FMD9) use F16= MHABD to view the MHABD Assistance Group Summary screen. Select the coverage type and use F16= AGBUDSUMM to view the Adult MO HealthNet Budget Summary screen press F17=INCSUM to view the Income Summary Detail screen and F18=EXPSUM to view the Expense Summary Detail screen to ensure all countable income and expenses are included in the budget.

0815.020.15 Medical Re-certifications (Utilization Reviews)

Medical re-certifications for NF, MHC and IMR level of care are not completed by Eligibility Specialists. These re-certifications are done by the Utilization Review Committees, as established through the Department of Health and Senior Services, Division of Senior and Disability Services.

When a change in level of care needs to be made as a result of a utilization review, the Division of Senior and Disability Services will notify the Eligibility Specialist of the change.

As a result of a utilization review, if COMRU sends a DA-125 to the Eligibility Specialist indicating that the participant is no longer eligible for the level of care s/he is receiving, follow the procedures in Section 0815.070.00 to determine eligibility for non-vendor MHABD.

1. Update the entry on the Facility and Placement Information Details screen (FACPLACE or FMJ4) in the DA-124A/B Level of Care field.
2. Enter a comment from the Facility and Placement Information Details screen (FACPLACE or FMJ4) noting the date the DA-125 was received and describing the verification of the change.
3. Enter a comment from the Eligibility Unit Member Role (EUMEMROL or FM3Z) screen describing the adjustment.
4. Complete the eligibility determination (EDRES) in FAMIS and authorize the adverse action to change the level of care or close the case.

   NOTE:  Always review the Budget Summary screen prior to authorizing a case action in FAMIS. From the MHABD Action Authorization screen (FMD9) use F16= MHABD to view the MHABD Assistance Group Summary screen. Select the coverage type and use F16= AGBUDSUMM to view the Adult MO HealthNet Budget Summary screen press F17=INCSUM to view the Income Summary Detail screen and F18=EXPSUM to view the Expense Summary Detail screen to ensure all countable income and expenses are included in the budget.