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TAR Discharge Planning Option (tar dis)

By Ashley Reyes,2014-11-26 17:32
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TAR Discharge Planning Option (tar dis)

    tar dis

    TAR Discharge Planning Option 1

The Discharge Planning Option (DPO) was implemented to facilitate the discharge of patients from acute

    care hospitals to home, board and care, or a nursing facility in response to a report by the State of

    California’s Little Hoover Commission. These discharge planning procedures do not apply to patients enrolled in Medi-Cal Managed Care plans.

INTRODUCTION

    Initiating Discharge Upon admission of a Medi-Cal patient to an acute hospital with Planning Option on-site review, the Medi-Cal Consultant begins working closely with

    the discharge planner to determine the post discharge needs of the

    patient. See Figure 3 on a following page for a sample communications

    log to facilitate communication between the Medi-Cal Consultant and

    discharge planner.

     Once a patient’s post discharge needs are determined, the acute care

    hospital must complete one of the following forms depending on the

    place of service where the patient is being discharged:

    ; Medi-Cal Managed Care Authorization form (55-1) for post

    discharge community services, including allied health, dialysis,

    and home health services.

    ; Long Term Care Treatment Authorization Request (20-1) for

    post discharge Nursing Facility services.

TAR Completion Instructions Instructions for completing the Medi-Cal Managed Care Authorization

    form (55-1) are included in this section. Refer to the TAR Discharge

    Planning Option Codes section in the appropriate Part 2 manual for

    the listing of services that may be requested on this form.

     For instructions on how to complete the Long Term Care Treatment

    Request (20-1), refer to the TAR Discharge Option Plan for Long

    Term Care section in the appropriate Part 2 manual.

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MEDI-CAL MANAGED CARE AUTHORIZATION FORM (55-1)

Post Discharge The Medi-Cal Managed Care Authorization form (55-1) is used to

    Community Services request Medi-Cal field office authorization for post discharge

    community services. See Figures 1 and 2 on a following page for

    examples of the 55-1.

    Discharge Planner Review The DPO process is initiated by the acute hospital discharge planner

    prior to the patient’s anticipated discharge. After identifying

    community services for post discharge needs, the discharge planner

    completes a 55-1 and presents it to the Medi-Cal Consultant for

    approval. The Medi-Cal Consultant has the authority to approve a

    specified range of medically necessary post discharge services. The

    55-1 is signed by a representative of the acute hospital. A physician’s

    signature is not necessary.

     Note: If the patient needs Long Term Care facility post discharge

    services, the discharge planner will fill out a Long Term Care

    Treatment Authorization Request (20-1) instead of a 55-1.

    Refer to the TAR Discharge Planning Option for Long Term

    Care section in the appropriate Part 2 manual.

    Medi-Cal Consultant The Medi-Cal Consultant reviews the patient’s chart and the items

    and

    Review services requested on the 55-1 to verify the presence of a physician’s

    order for post discharge services and to determine medical necessity.

    The consultant may also observe or interview the patient to determine

    appropriate post discharge services.

     The consultant then approves appropriate services and completes the

    11-digit TAR Control Number by adding a two-digit prefix and one-

    digit suffix.

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    Post Discharge Providers The acute hospital is responsible for identifying Medi-Cal providers

    willing and able to provide post discharge services (post discharge

    providers).

     The discharge planner will contact providers in the community who

    agree to render post discharge services and inform the providers of

    the 11-digit TAR Control Number. Post discharge providers use this

    11-digit number to bill for services. After the field office enters the

     55-1 into the TAR master file, an Adjudication Response (AR) will be

     sent to the post discharge provider.

    For additional information about ARs, providers may refer to “TAR

    Status on Adjudication Response” in the TAR Overview section of the

    Part 1 manual.

    Multiple Post Discharge The discharge planner may list up to four post discharge services, Services providers or a combination of both services and providers on one

    Medi-Cal Managed Care Authorization form. If more than four post

    discharge services or providers are requested, additional 55-1 forms

    must be used.

     Note: Community providers must use the TAR Control Number that

    appears on the line(s) authorizing their services.

    Exceptions to Discharge Discharge Planning Option (DPO) is not initiated for patients pending Planning Option Medi-Cal eligibility, who are eligible for California Children Services

    or are enrolled in Medi-Cal Managed Care health care plans (county

    health initiatives, Prepaid Health Plans or Primary Care Case

    Management plans). If the patient is eligible for both Medicare and

    Medi-Cal, DPO may only be initiated for services not covered by the

    Medicare program.

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    Completing the Medi-Cal The discharge planner is responsible for completing item numbers Managed Care 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 14, 15, 16, 18, 23, 24, 25, 26 and 27 Authorization Form (55-1) on the Medi-Cal Managed Care Authorization form (55-1) for services

    provided by post discharge community providers. An example of a

    correctly completed 55-1 for post discharge community services is

    shown below.

HOSPITAL NAME & ADDRESS. PATIENT’S AUTHORIZED REPRESENTATIVE. CONFIDENTIAL Patient Information Community Acute Hospital Raquel Conrad NAME 123 Health Road MEDI-CAL 789 River Road ADDRESS Anytown, CA 95814 Anytown, CA 95814 MANAGED CARE AUTHORIZATION

    PATIENT INFORMATION

     PATIENT NAME. AGE. SEX. TRANSFER TO: MEDI-CAL NUMBER Conrad, Jose M 58 X MALE FEMALE COUNTY CODE XPATIENT ADDRESS. DATE OF BIRTH. 3 4 AID CODE 6 0 HOME BOARD & CARE 789 River Road SOCIAL SECURITY NO. 06 / 30 / 42 MM DD YY 1 1 1 2 2 3 3 3 3 NF/ICF Anytown, CA 95814

    DIAGNOSIS MEDICARE? YES NO ICD-9-CM 897.2 S/P traumatic amputation, above knee, left leg

    SPECIFIC SERVICES REQUESTED PROVIDER NO. DCN. SERV. CAT. DRUG /OTHER PROVIDER NAME: Caring Home Health HHA666660 Agency (916) 555-1111 COMMENTS Open draining stump wound requires daily dressing changes for one week FROM TO 3x week for 2 weeks, 2x week for one week.

     PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 1 Y N UNITS Skilled Nursing Services 15 Z6900 50012821 PROVIDER NO. DCN. SERV. CAT. DRUG /OTHER PROVIDER NAME: Caring Home Health HHA666660 Agency (916) 555-1111

    COMMENTSTo continue range of motion transfer ambulation with assistive device FROM TO 3x week for 3 weeks. PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 2 Y N UNITS Z6904 50012821 Physical Therapy Services 9

    PROVIDER NO. DCN. SERV. CAT. DRUG /OTHER PROVIDER NAME: Caring Home Health HHA666660 Agency (916) 555-1111 To continue goal of independent wheelchair transfer from bed to commode COMMENTSFROM TO 3x week for 3 weeks. PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 3 Y N UNITS Z6906 Occupational Therapy Services 9 50012821 PROVIDER NO. DCN. SERV. CAT. DRUG /OTHER PROVIDER NAME: Hospital Equipment DME234560 Inc. (916) 555-2222

    COMMENTSFROM TO Requires varying bed height to facilitate patient transfers and personal care.

     PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 1 month rental of semi-electric 4 Y N UNITS E0295 hospital bed. 1 50012821

    NOTE: Approval does not guarantee payment! Patient’s eligibility must be current and claims properly submitted To the best of my knowledge the above information is true, accurate and complete, MEDI-CAL CONSULTANT COMMENTS: MEDI-CAL CONSULTANT and the requested services are medically necessary for the patient. I.D.# DATE

     T. J. Jones RN 11/18/04 SIGNATURE OF PHYSICIAN OR PROVIDER DATE

    Figure 1. Sample Completed Medi-Cal Managed Care Authorization Form (55-1).

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    HOSPITAL NAME & ADDRESS. PATIENT’S AUTHORIZED REPRESENTATIVE. CONFIDENTIAL Patient Information 9 1 NAME MEDI-CAL ADDRESS MANAGED CARE AUTHORIZATION

    PATIENT INFORMATION

     PATIENT NAME. AGE. SEX. 5 TRANSFER TO: 2 MEDI-CAL NUMBER 4 MALE FEMALE AID CODE HOME COUNTY CODE DATE OF BIRTH. 7 PATIENT ADDRESS. 6 BOARD & CARE 8 3 / / 3 SOCIAL SECURITY NO. NF/ICF MM DD YY 10 DIAGNOSIS MEDICARE? YES NO ICD-9-CM 11

    SPECIFIC SERVICES REQUESTED PROVIDER NO. PROVIDER NAME: DCN. SERV. CAT. DRUG /OTHER 13 12 16 15 14 COMMENTS FROM TO 18 17 PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 1 24 Y N UNITS 23 20 25 21 50012821 22 19 PROVIDER NO. PROVIDER NAME: DCN. SERV. CAT. DRUG /OTHER

    COMMENTS FROM TO

     PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 2 Y N UNITS 50012821

    PROVIDER NO. PROVIDER NAME: DCN. SERV. CAT. DRUG /OTHER COMMENTSFROM TO

     PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 3 Y N UNITS 50012821 PROVIDER NO. PROVIDER NAME: DCN. SERV. CAT. DRUG /OTHER

    COMMENTSFROM TO

     PREFIX TAR CONTROL NO. P.I. JVR ACTION AUTHORIZED PROCEDURE SERVICE DESCRIPTION: QTY. 4 Y N UNITS 50012821

    NOTE: Approval does not guarantee payment! Patient’s eligibility must be current and claims properly submitted To the best of my knowledge the above information is true, accurate and complete, MEDI-CAL CONSULTANT COMMENTS: MEDI-CAL CONSULTANT and the requested services are medically necessary for the patient. 28 I.D.# DATE 29 30 26 27 31 SIGNATURE OF PHYSICIAN OR PROVIDER DATE

    Figure 2. Sample Medi-Cal Managed Care Authorization Form (55-1). 2 TAR Discharge Planning Option August 2000

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    Explanation of Form Items The following item numbers and descriptions correspond to the

    sample Medi-Cal Managed Care Authorization shown on a previous

    page. All items must be completed unless otherwise noted in these

    instructions.

    Note: Authorization does not guarantee payment. Be sure the

    patient’s eligibility is current and that the patient is not enrolled

    in a Medi-Cal Managed Care Plan. To receive payment, the

    patient must be eligible for the date of service and all claims

    submitted properly.

     Item Description

     1. HOSPITAL NAME & ADDRESS. Enter the name and

    address of the discharging acute hospital. If the patient is

    transferring or being admitted to an acute hospital (for

    example, acute rehabilitation), enter the name and address

    of the admitting hospital. If the patient is not in an acute

    hospital, leave blank.

    2. PATIENT NAME. Enter the patient’s last name, first name

    and middle initial (if known). Avoid nicknames or aliases.

    Newborn Infant When submitting a claim for a newborn infant using the

    mother’s ID number, enter the infant’s name, sex and date

    of birth in the appropriate spaces. If the infant has not yet

    been named, write the mother’s last name followed by

    “Baby Boy” or “Baby Girl” (for example, Jones, Baby Girl).

    If newborn infants from a multiple birth are being

    authorized, each newborn must also be designated by

    number or letter (for example, Jones, Baby Girl, Twin A).

    Services to an infant may be authorized and billed with the

    mother’s ID for the month of birth and the following month

    only. After this time, the infant must have his or her own

    Medi-Cal ID number.

     3. PATIENT ADDRESS. Enter the patient’s residence

    address.

     4. AGE. Enter the patient’s current age.

     5. SEX. Enter an “X” in the Male box if the patient is male.

    Enter an “X” in the Female box if the patient is female.

     6. DATE OF BIRTH. Enter the month of birth in the “MM”

    area, the day of birth in the “DD” area and the year of birth

    in the “YY” area. For example, June 30, 1942 would be

    entered as 06 30 42.

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Item Description

7. MEDI-CAL NUMBER/COUNTY CODE/AID CODE/

    SOCIAL SECURITY NO. Enter either the patient’s

    14-character Medi-Cal ID number or 9-character Social

    Security Number in the appropriate space.

    Note: The two-digit county and aid codes must be entered

    in the appropriate boxes when using the Social

    Security Number.

    8. TRANSFER TO. Enter an “X” in the box indicating where

    the patient will be transferred or discharged to. If the

    patient is transferred, enter the name of the admitting

    hospital in the Comments box in Section 1 (Item 18).

9. PATIENT’S AUTHORIZED REPRESENTATIVE. If

    applicable, enter the name and mailing address of the

    patient’s authorized representative, representative payee,

    conservator, legal representative or other representative

    handling the patient’s medical and personal affairs.

10. MEDICARE? Enter an “X” in the Yes box if the patient has

    Medicare. Enter an “X” in the No box if the patient does not

    have Medicare.

11. ICD-9-CM/DIAGNOSIS. Enter the patient’s primary

    discharge diagnosis code on the ICD-9-CM line and the

    primary discharge diagnosis description in the Diagnosis

    box.

    12. DCN. Leave blank. For DHCS Fiscal Intermediary (FI)

    use only.

13. SERV. CAT. Leave blank. For FI use only.

    14. DRUG/OTHER. Circle Drug if requesting prior approval

    for drugs for the patient. Circle Other if requesting any

    other service for the patient.

    15. PROVIDER NO. Enter the rendering provider number.

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Item Description

16. PROVIDER NAME. Enter the name of the rendering

    provider. If space allows, enter the area code and

    telephone number of the rendering provider as well.

    17. FROM/TO. Leave blank. The Medi-Cal Consultant will fill

    in the valid dates of authorization in this area.

    Note: TAR-authorized services billed for dates of service

    outside the authorized “From/To” dates will not be

    paid.

    18. COMMENTS. Enter sufficient justification for the Medi-Cal

    Consultant to determine if the services are medically

    necessary. If necessary, attach additional information.

    Justification includes medical reasons why specific

    services are required by the patient and the frequency of

    required services. If the services requested will be

    provided in an acute hospital or Nursing Facility, enter the

    name of the facility in this box.

19. PREFIX/TAR CONTROL NO./P.I. Leave blank. The

    Medi-Cal Consultant will add a two-digit prefix and one-

    digit suffix to the pre-imprinted eight-digit number. The

    two-digit prefix will be different for each provider listed on

    the

    Medi-Cal Managed Care Authorization form.

     Enter the entire 11-digit TAR Control Number on your

    claim form when billing. This TAR Control Number serves

    as the initial admit TAR number when admitting a patient

    to an acute hospital (for example, acute rehabilitation). Do

    not attach a copy of the TAR to the claim form.

    20. JVR. Jackson v. Rank. Leave blank. For State use only.

    21. ACTION. Leave blank. The Medi-Cal Consultant will

    enter a “1” if the service is approved, a “2” if the service is

    modified or a “3” if the service is denied.

22. AUTHORIZED UNITS. Leave blank. The Medi-Cal

    Consultant will indicate if the service is authorized and the

    quantity authorized.

    23. PROCEDURE. Enter the five-character CPT-4, HCPCS

    level II or III procedure code, Drug NDC or the Medical

    Supply code, followed by a two-character modifier, if

    necessary.

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     Item Description

     24. SERVICE DESCRIPTION. Enter the name of the

    procedure, item or service requested. If requesting

    hospital days, enter “Hospital Day(s).”

    25. QTY. Enter the quantity of procedures, items, services or

    hospital days requested. If requesting monthly rental of a

    DME item, enter the number of months the rental will be

    required.

     12 25. Repeat the instructions for Items 12 through 25 for lines

    two through four if more than one post-discharge

    community service is requested, even if the different

    services will be rendered by the same provider.

     26. SIGNATURE OF PHYSICIAN OR PROVIDER.

     A representative of either the discharging acute hospital or

    the post-discharge community provider must sign on this

    line. A physician’s signature is not necessary.

     27. DATE. Enter the date the representative of the

    discharging acute hospital or the post-discharge

    community provider signed the form.

     28. MEDI-CAL CONSULTANT COMMENTS. Leave blank.

    The Medi-Cal Consultant will enter any pertinent

    comments in this box.

     29. MEDI-CAL CONSULTANT I.D.#. Leave blank. The

    Medi-Cal Consultant will enter his or her identification

    number or initials in this box.

     30. DATE. Leave blank. The Medi-Cal Consultant will enter

    the date he or she signed the form in this box.

     31. MEDI-CAL CONSULTANT SIGNATURE. The Medi-Cal

    Consultant will sign the form next to or under the Medi-Cal

    Consultant I.D.# and Date boxes.

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