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1 TAR Discharge Planning Option for Long Term Care
This section gives instructions on how to complete an authorization request using the Long Term Care
Treatment Authorization Request (LTC TAR, 20-1).
Post-Discharge Nursing The Long Term Care Treatment Authorization Request (20-1)
Facility Services is used to request initial authorization for post-discharge Nursing
Facility (NF) services. The Medi-Cal consultant will write “DPT” in the
upper left corner of the 20-1 form and in the comments section to
differentiate the Discharge Planning TAR from a normal 20-1 TAR.
For an example of a correctly completed 20-1 for NF care, see
Figure 1 on a following page.
Note: If the patient needs post-discharge community services, the
discharge planner will fill out a Medi-Cal Managed Care
Authorization form (55-1) instead of a 20-1. Refer to the
TAR Discharge Planning Option section in this manual for
instructions on completing the 55-1.
Patients Discharged to If the patient is to be discharged to a NF, a 20-1 must be initiated a Nursing Facility by the acute care hospital discharge planner.
The 20-1 is then presented to the Medi-Cal consultant who will review
the medical record and, if appropriate, authorize the NF level of care.
The consultant will also review the PASRR Screening Document and
enter the following information in the Comments/Explanation section
of the 20-1:
; Date the PASRR Screening Document was completed and the
date of the referral to Level II, if appropriate
; Level of care authorized
; Indicate if a Medicare denial is needed
; Date and signature of Medi-Cal consultant
The Medi-Cal consultant has the authority to approve a stay of up to
one year in a NF. The consultant will make this determination based
on the patient’s chart and the results of the PASRR Screening
Instructions on how to complete the screening document are in the
Preadmission Screening Resident Review (PASRR) section in the
appropriate Part 2 manual.
A patient who is referred for Level II evaluation will only be approved
for a four-month maximum NF stay.
2 – TAR Discharge Planning Option for Long Term Care August 2002
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Where to Submit The NF is responsible for completing the 20-1 and forwarding it to the 20-1 TAR Form the San Bernardino Medi-Cal Field Office.
The 20-1 and PASRR Screening Document must accompany the
patient to the NF. If post-discharge community services have been
requested for the patient on a 55-1, and a post-discharge provider has
not been found prior to admission to the NF, the authorized 55-1 must
also accompany the patient to the NF. The NF is responsible for
locating a willing post-discharge community provider and giving the
provider the copy of the 55-1. The post-discharge provider completes
the 55-1 and submits it to the field office. In this case, all timeliness
guidelines have been met.
Medicare/Medi-Cal For Medicare/Medi-Cal crossover patients admitted to an NF under Crossover Patients Medicare reimbursement, a 20-1 must be initiated by the acute care
hospital, reviewed and authorized by the Medi-Cal consultant and
sent with the patient to the NF along with a copy of the PASRR
Screening Document. This allows NF providers to bill Medi-Cal as
soon as the patient's Medicare benefits have exhausted without
waiting for further TAR approval. In this case, NF providers must
include a copy of the Medicare denial when submitting the 20-1 to the
2 – TAR Discharge Planning Option for Long Term Care July 2002
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3 LONG TERM CARE TREATMENT AUTHORIZATION REQUEST STATE OF CONFIDENTIAL 1 FOR FI USE ONLY CALIFORNIA DEPARTMENSTATE PATIENT HEALTH SERVICES T PLEASE TYPE USE INFORMATION 5 REQUIRE ALLINFORMATION ONLY CCN Elite Elite Pic DPT aTypewriter SERVICE PicaCATEGORY SKILLECHECK ONLY ONE BOX REAUTHOR- INTERMEDIATE SPECIAL PROGRAM I.C.F.AlignmentCARE FORM LIC 231 ATTACHED NURSING CARE D.D. D IZATION TRANSFER INITIALX
.. REQUEST IS PROVIDER PHONE NO. 18 PROVIDER; YOUR REQUEST IS: VERBAL CONTROL NO. RETROACTIVE? . 2 1 APPROVED AS ( ) APPROVED 213 555-1234 X MODIFIED AS AREA NO YES SEE COMMENTS BELOW REQUESTED PROVIDER NAME AND ADDRESS FI USE ONLY 4DEFERRED 3 DENIED 2 PROVIDER NUMBER REASON AND ALTER- 3 4 NATE TREATMENT LTC45678G PLAN RECOMMENDED ; BELOW HAPPY HOME ; 5 JACKSON VS RANK 6 5 123 CARE ROAD ; PARAGRAPH CODE HOLLYWOOD, CA 90012 ; ; BY: (MEDI-CAL CONSULTANT) X 01 01 MEDICAL RECORD NUMBER I D NO DATE REVIEW MEDI-CAL IDENTIFICATION NO. PEND. FIRST, M.I.) 19 20 COMMENTS PATIENT NAME (LAST, 8 7 INDICATOR 6 333445555 SMITH, DOROTHY D. ADMIT SOCIAL SECURITY CLAIM NO. DATE OF BIRTH MEDICARE ADMIT DATE. DATE SEX COMMENTS/EXPLANATION 9 12 13 14 15 10 11 01 12 09 12 21 99 333445555 DPT F FROM THIS SERVICE STATUS BENEFITS EXHAUSTED
(FROM) DATE (T0) DATE PRIM. DX CODE PASRR COMPLETED 01/07/00, PERIOD OF CARE 16 REQUESTED NO REFERRAL MADE. APPROVED CURRENT DIAGNOSES A. (PRIMARY):FOR N.F. LEVEL B FOR ONE YEAR. (SECONDARY) PLEASE ATTACH APPROPRIATE NAME OF FORMER FACILITY FACILITY Joyce Johnson MEDICARE DENIAL. B. DAILY MEDICATIONS (NAME, DOSAGE, FREQUENCYJOYCE JOHNSON MEDI-CAL NURSE C. PATIENT'S GENERAL CONDITION, LIMITATIONS AND NURSING PROCEDURES REQUIRED: TOTALLY AMBULATORY CONFINED TO BEDRIDDEN SPOON FED AMBULATORY INCONTINENT W. ASSISTANCE WHEELCHAIR SPECIFY M D M D N0 SPECIAL SNF ICF ICF DD SOB REHAB PROGRAM 4 FOCUS REVIEW 23 FROM (Y/N) D. DIET E. ATTENDING PHYSICIAN'S LAST VISIT (DATE): (DATE) CHART REVIEWED 24. THRU (Y/N) (DATE) PHYSICIAN NAME & PHONE NO. PATIENT'S AUTHORIZED REPRESENTATIVE (IF ANY) PROLONGED ADMIN. DAYS ENTER NAME AND ADDRESS: CARE (BED NOT AVAILABLE) PENDING (REQUEST FOR ; FAIR HEARING) Y N ; ; PHYSICIAN MEDI-CAL 17 25 ; RETROACTIVE AUTHORIZATION GRANTED IN ACCORDANCE IDENTIFICATION NO. WITH SECTION 51003(8) TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE, ACCURATE, AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT. OFFICE SEQUENCE DATE SIGNATURE OF PHYSICIAN 20-IZ 12/87 NOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT'S ELIGIBILITY. BE SURE THE IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICE.
Figure 1. Sample completed Long Term Care Authorization Request (20-1) for Discharge Planning.2 – TAR Discharge Planning Option for Long Term Care August 2000
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This list outlines the steps involved when requesting and authorizing Nursing Facility (NF) level of care for Medi-Cal patients under Discharge Planning Option. Providers may wish to photocopy this page and post it in the office.
Discharge Planning Option Instructions
Patient Discharged From a Delegated Acute Hospital to a Nursing Facility
Long Term Care Discharge Planning Treatment Authorization Request (20-1)
1. The patient is admitted to an acute care hospital participating in the Discharge Planning Option
2. The Medi-Cal Consultant approves the Treatment Authorization Request (TAR) for the initial
admission if criteria are met.
3. The patient appears to need NF care. The discharge planner initiates communication with the
4. The attending physician orders NF care. The physician's order is placed in the patient's chart.
5. A representative of the acute care hospital completes the PASRR Screening Document and
refers the patient to Level II, if appropriate. (Refer to the Preadmission Screening Resident
Review [PASRR] section in the appropriate Part 2 manual.)
6. The discharge planner completes the patient name and Medi-Cal number fields (Boxes 6 and 7)
on a Long Term Care Treatment Authorization Request (20-1).
7. The Medi-Cal Consultant reviews the 20-1, the PASRR Screening Document and the patient's
chart to verify the information and determine medical necessity for the requested level of care,
and approves the 20-1 if criteria are met.
8. The discharge planner locates a NF provider willing to accept the patient.
9. The 20-1 and PASRR Screening Document are sent to the NF with the patient.
10. The NF completes the 20-1 and sends it to the San Bernardino Medi-Cal Field Office.
2 – TAR Discharge Planning Option for Long Term Care August 2000