PASRR Level I

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Federal law (42 CFR 483.128) mandates that states provide a Level I screen for all applicants to Medicaid-certified nursing facilities to identify residents with serious mental illness (SMI), mental retardation (MR), or a related condition (RC). For residents with no evidence or diagnosis of SMI, MR, or RC, the initial Level I screen remains valid unless there is a significant change in status.

Referred to as the Level I or identification screen, specific diagnostic and functional questions about an individual are raised to identify those persons with mental illness, mental retardation, and conditions related to mental retardation. The Level I and, when required, the Level II screens must be performed prior to nursing facility admission (excluding those situations discussed in Section II.D.ii of this manual).

A Level I screen remains valid unless there is a significant change in a resident's status that affects his/her mental health or mental retardation treatment needs. This means that if a resident is discovered to have SMI, MR or RC after the Level I was performed, the receiving facility must call the PASRR contractor to perform an updated Level I. Updates to the Level I should also occur if a resident in the PASRR process exhibits an increase in behavioral problems or symptoms or if an individual with MR makes significant medical improvement and may be a candidate for special treatment services. Level I screens do not need to be done again except when a resident with known or suspected SMI, MR or RC has not been previously assessed through the PASRR contractor or if no prior Level I has been completed.

It is the responsibility of the referral source to initiate the Level I screen with EDS before an applicant is admitted to a nursing facility. Admitting facilities are then responsible for re-initiating contact for residents meeting the criteria explained in Section II.D of this manual. Failure to notify EDS of a patient's admission may result in a lapse in the screenings for Level II PASRR individuals.

The Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SAS) PASRR Unit is the agency which will make final determinations regarding appropriateness of placement and need for specialized services and, in cases where specialized services are determined as necessary, the DMH/DD/SAS will arrange for provision of those services.

The referral source completes the North Carolina Level I Screening Form (see Attachment B) and contacts the PASRR contractor for a PASRR number either by:
Level I identification screens apply only to Medicaid certified nursing facility applicants/residents (swing-beds are exempt) and occur:
  1. Prior to nursing facility admission;
  2. Whenever there is a significant change in status in a nursing facility resident (referred to as a status change), See Section II.D.i.
Level I screens do not apply to the following individuals:
  1. Individuals who have had a previous Level I and who are re-admitted to a nursing facility after treatment in a hospital (unless there has been a significant change in status for an individual with MI or MR/RC. Such cases would be referred to EDS following readmission).
  2. Individuals who have had a previous PASRR screening and transfer from one facility to another. However, a Tracking Form should be submitted to EDS by the receiving and discharging facilities to report the transfer of these individuals.
  3. Individuals admitted to swing beds, adult care home beds, rest home beds, or other facility/bed types that do not participate in the Medicaid program or are not considered Medicaid certified nursing facilities.

Other than the exceptions noted above, all applicants for admission to Medicaid certified nursing facilities must have a Level I PASRR screen to determine the potential presence of serious mental illness,mental retardation, or a related condition prior to their admission to nursing facility care. Each of these conditions is defined in Section IV.D.

Level I Outcomes

As a result of the Level I screen, the following outcomes may occur that include a negative or positive finding for the patient's eligibility for the PASRR population either with a serious mental illness, mental retardation, or condition related to mental retardation:

Negative Finding: When the individual is determined to be exempt from the Level II PASRR population ("A" alpha character at the end of the review number) and receives or is applying for Medicaid benefits, the facility should follow general procedures for Medicaid level of care screens through the EDS LTC prior approval unit. The referral source is provided with a PASRR review number which s/he will be required to supply to the EDS LTC staff at the time of that screen. That number must be entered into block ten (10) of the FL2. The EDS LTC department will then issue a Service Review Number (SRN) based upon NF level of care and this number will continue to be used for Medicaid billing purposes. If the individual is approved for admission, the receiving facility must contact EDS upon the individual's admission to request a written copy of the Level I approval for the individual's records.

Negative Finding: When the individual is determined to be exempt from the Level II PASRR population ("A" alpha character at the end of the review number) and is not a Medicaid recipient or applicant, the facility should follow its general admission procedures and the referral source will be provided with notification of this determination through provider link or fax.

Positive Finding: When the individual is found to meet the Level II PASRR criteria by the EDS nurse analyst, the referral source will be asked to forward specific current information identified in Section II.C.i of this manual (e.g., history and physical examination, the MDS, FL-2, physician notes, available intellectual testing, etc.). Upon receipt of that information, the need for a Level II face to face assessment will be determined. If the patient meets federal criteria for Level II status, a referral is initiated by the EDS PASRR nurse and the referral source is notified via Provider Link of the referral status of their request. The review process will be completed within 7 business days of the Level II referral (day of the initial written notification that the patient meets Level II PASRR population criteria). The written notification of the Level II determination will be provided to the referral source by the 7th business day. During the written notification, the facility will be provided with an EDS PASRR number for the screened individual. If that individual is a Medicaid recipient or applicant, the referral source should then initiate contact with the EDS LTC team for nursing facility level of care determination and should provide the assigned EDS PASRR number. The EDS LTC team will then issue an authorization number (also called a service review number) which will be used for Medicaid billing. The receiving facility must contact EDS upon the individual's admission to request a written copy of the Level II approval for the individual's records. This can be accomplished by submitting a tracking form via facsimile, mail, or electronic submission.

When the submitted Level I screen indicates that the individual does have indicators of a serious mental illness or mental retardation, s/he will be referred for a Level II face-to-face evaluation. The Level II must be completed prior to the individual's admission to a Medicaid certified nursing facility (regardless of whether the individual is a Medicaid recipient or is a private payee). The referral source will be notified of the need for a Level II screen during the initial notification via Provider Link or fax, and the process discussed in Section II.C.i called Pre-admission Screen PAS is initiated. It is important to note that an identified PASRR Level I screen with suspected MI/MR/RC can not be completed (referred for a face-to-face assessment) until a FL-2 or MDS, and current History and Physical are received by the EDS clinical reviewer.