Preadmission Screening and Resident Review (PASRR)

The PASRR program is a federal statutory requirement (see 42 CFR 483 Subpart C) that mandates the review of every individual who applies to or resides in a Medicaid-certified nursing facility, regardless of the source of payment for nursing facility services.

PASRR became effective January 1989 as a result of the Omnibus Budget Reconciliation Act (OBRA) of 1987 (P.L. 100-203). This section of OBRA was enacted to assure that individuals with serious mental illness (SMI), mental retardation (MR), and/or conditions related to mental retardation (RC) entering or residing in Medicaid-certified nursing facilities receive appropriate placement and services. This federal regulation mandates at minimum a Level I review of every individual who applies to or resides in Medicaid-certified nursing facilities regardless of the source of payment for nursing facility services.

Who Is Subject to PASRR Screens?

In accordance with 42 CFR 483.106, all applicants and residents of Medicaid-certified nursing facilities must be screened through the Level I and, if appropriate, the Level II process.

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Note: Hospital swing beds, Community Alternatives Program services, and nursing facilities that are not Medicaid certified are exempt from Level I and Level II PASRR screens. A small number of nursing facilities in North Carolina have a distinct part that participates in the Medicaid program as a nursing facility and another distinct part that participates in the Medicare program as a skilled nursing facility. Persons seeking admission to the Medicare Division of Medical Assistance Clinical Coverage Policy No. 2B-1 Nursing Facilities Original Effective Date: July 1, 1991 Revised Date: January 1, 2009 03302009 9 distinct part, as long as that part is not Medicaid certified, are also exempt from the Level I and Level II processes.

An individual who is transferred from any of these placements into a Medicaid-certified nursing facility bed (or Medicaid-certified part of a nursing facility) must have a Level I and, if applicable, a Level II screen before that transfer can occur.

PASRR screenings must be performed prior to admission and annually thereafter for persons who are suspected as meeting the federal definitions for MI, MR, and/or RC. A Level I identification screening must be performed before anyone, regardless of payment source, can be admitted to any Medicaid certified nursing facility. When the Level I screening indicates the possibility of MI, MR, or RC, a Level II face to face in-depth evaluation must be performed to assess for nursing facility placement and for potential specialized care needs of the individual.

PASRR Screening Procedures

The following procedures will address PASRR Level I and Level II screens and their processes, as well as the State's plans for assuring that PASRR screens have been performed for all appropriate current nursing facility (NF) residents placed in or residing at Medicaid certified facilities. The sections above reviews the two PASRR processes (both Level I and Level II reviews). The other sections provide protocol and supply general definitions and other administrative information regarding PASRR.

EDS is the DMA contractor responsible for managing the Level I and Level II processes in North Carolina. Screening information may be communicated to EDS by the following:

  • Online - Get Started Today!
  • Fax (1-866-216-3424)
  • By Mail - EDS, P.O. Box 30015, Raleigh NC 27622-0015

The referral source (i.e., hospital discharge planner, NF staff, county case worker, etc.) is responsible for contacting EDS before any applicant, regardless of payment source, is admitted to a North Carolina Medicaid certified NF. EDS reviewers utilize the screening protocol found in Appendix A of this manual to arrive at Level I determinations. The referral source should be prepared to provide a Level I Screening Form that outlines specific information regarding the individual's history, behaviors, diagnoses, medical and pharmacological treatment. Once information is submitted electronically, a Level I determination will be available usually realtime but in some cases will be returned within six hours of receipt of information by EDS. A Level I determination can have one of two outcomes, either "approved" or notification of a "referral for Level II face-to-face evaluation".

For persons who are Medicaid applicants or recipients, the Level I and Level II (if applicable) screens must be performed prior to contact with the EDS Long Term Care (LTC) team, for nursing facility placement. Following completion of the appropriate screen(s), EDS will assign an authorization number. That number must be noted in block ten (10) of the FL2. This number must be communicated to EDS at the time of the nursing facility prior approval request. In turn, EDS will issue a prior approval number (also called the service review number) which will continue to be the Medicaid billing number.

The EDS Level I PASRR number is usually assigned the day of screening and is communicated to the referral source when the screen is complete. For Level II identified individuals (persons suspected of meeting criteria for MI and/or MR/RC), the review number is assigned when the Level II is completed (usually within seven business days from the referral for a Level II evaluation). EDS will communicate both the screening results and the PASRR number at the conclusion of the Level II evaluation process via Provider Link and fax.

For general information on procedures and review status, Please contact us by calling 1-800-688-6696 Option 7 between 8:00 am and 4:30 pm. For problem resolution or policy clarification, please request to speak with an NC PASRR nurse analyst or PASRR supervisor.

Level I Screens

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. Read More...

Level II Screens

Any applicant to a Medicaid-certified nursing facility whose Level I screen indicates the possible presence of SMI, MR, or RC must undergo a Level II screen. Level II screens are federally mandated (42 CFR 483.128) to be performed on-site and prior to admission to the nursing facility.   Read More...

Level II Screen Postponements

Federal regulations (42 CFR 483.130) allow short-term nursing facility admissions for some applicants with SMI, MR, or RC. These time-limited approvals are authorized during the Level I screen process when any of the following four circumstances are applicable:

  • a. Convalescent care (30-day approval): applies to admissions to nursing facilities directly from acute care hospitals. Note: Federal regulations (42 CFR 483.106) state that an individual must need 30 days or less of nursing facility care for the hospitalization condition for this approval to be granted. The attending physician must provide certification that the nursing facility stay is not expected to exceed 30 days.
  • b. Emergency (7-day approval): applies when the individual needs emergency protective service placement
  • c. Delirium (7-day approval): applies to individuals suspected of having SMI, MR, or RC but whose delirium state prevents accurate completion of the Level I and/or Level II processes
  • d. Respite (7-day approval): applies to individuals whose in-home caregivers need temporary respite

Annual Resident Review for Level II Screens

Annual Resident Reviews (ARRs) are no longer required. Select Here to read the story...

Status Changes

Residents who exhibit a significant change in mental health or mental retardation needs must be re-screened through Level I as a status change. A change in status can occur for residents with newly discovered diagnoses or symptoms of SMI, MR, and RC, as well as for residents known to have SMI, MR or RC but whose treatment needs for those conditions change significantly.   Read More...

Continued Stays

If residence in the facility is expected to extend beyond the end date shown on the initial Level I screen, further approval and evaluation, as authorized by 42 CFR 483.130(e), must be obtained before the authorized period ends. The admitting facility is responsible for initiating further assessment through an updated Level I evaluation

  • within 5 calendar days of the individual's date of admission for 7-day approvals,
  • within 25 calendar days for 30-day approvals, and
  • within 50 calendar days for 60-day approvals. Note: If the individual is Medicaid eligible and is approved for continued stay through the updated Level I/II process, Medicaid's fiscal agent must be contacted for payment to continue.

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