INSTRUCTIONS
FOR COMPLETING THE
REFERRAL FORM FOR
MEDICAL ELIGIBILITY DETERMINATION (MED) ASSESSMENT
OFFICE OF ELDER SERVICES
October 30, 2009
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CONFIDENTIALITY REQUIREMENTS
IT IS CRUCIAL THAT ALL INFORMATION GATHERED FROM ANY SOURCE BE TREATED AS
CONFIDENTIAL: NO INFORMATION CAN BE DIVULGED BY PROVIDERS IN ANY WAY
WITHOUT A RELEASE OF INFORMATION AUTHORIZATION.
BACKGROUND INFORMATION
This referral form will collect some of the applicant's demographic information as well as pertinent
information to assist in the assessment process. This information will be forwarded to the RN assessor and
certain items will need to be verified at the time the assessment is completed. Consumers need to give
permission to release information contained in this section to be shared with other providers. For a referral
to be considered complete and timely by the assessing services agency, the shaded areas MUST be
completed by provider agencies, hospitals or nursing facilities. If information required is not
completed, delays in completion of the assessment may occur and may result in payment issues for the
provider.
1. REFERRAL DATE: This date establishes a common reference point to indicate the start of the
assessment process based on the date this referral was forwarded to the assessing services agency. For the
month and day of the referral, enter two digits each, using zero (0) in the first box for a 1-digit month or
day, use four digits for the year.
2. APPLICANT NAME: Print applicant's legal name clearly, using capital letters for first name, middle
initial and last name.
3. BIRTH DATE: Use all boxes. For a one-digit month or day, place a zero in the first box. For example,
January 2, 1918, should be entered as 01-02-1918.
4. GENDER: Enter "1" for "Male" or "2" for "Female."
5. MARITAL STATUS: Choose the answer that best describes the applicant's current marital status.
6. CITIZENSHIP: Choose one answer from “1” U. S. Citizen, “2” Legal alien, or “3” Other.
7. PRIMARY LANGUAGE: Code for the language that the person primarily speaks or understands. Enter
the number from Language List found at the end of these instructions. For example, "0" for English, "1"
for French, “2” for Spanish, “84” for Vietnamese. Enter “3” for „Other‟ for any language spoken by
person that is not found on Language List. Specify „Other‟ language in space provided. The Department
must assure provision of an interpreter and cannot do so without knowing the primary language.
7a. Interpreter Required: Check when it is known that consumer will need an interpreter to assist assessor
in conducting the assessment. Check 0-No 1-Yes 2-Not Known.
8. RACE/ETHNICITY: Consult the person as necessary. Enter the race or ethnic category within which
the person places self. This is an optional question that can be left blank if the person prefers not to
answer.
9. RESIDENCE ADDRESS: Give applicant's residential address and phone number at time of assessment.
If person is in the hospital, give applicant's address prior to admission. If person is currently at a
residential care, assisted living or nursing facility, give the name and address of that facility.
PLEASE ENTER THE FOLLOWING NUMBERS, STARTING IN THE LEFTMOST BOX.
Enter one digit in each box. If there is no number, leave the boxes blank and check 0-NA for Not
Applicable. Check the numbers to make sure you entered the digits correctly.
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10. MAINECARE NO.: Enter the applicant's MaineCare number if applicable. This is a nine digit number
issued by the State. The number is considered valid only when the assessor actually verifies the number
on the MaineCare card. If there is no MaineCare number check 0-NA for Not Applicable.
11. MEDICARE NO.: Enter the applicant's Medicare number, if applicable. Be sure to include any letters
that follow the Medicare number. If there is no Medicare number check 0-NA for Not Applicable.
12. SOCIAL SECURITY NO.: Enter the applicant's Social Security number. This is a nine-digit number.
13. CURRENT INCOME SUMMARY: Enter all sources of income and indicate whether the recipient is
the applicant or spouse. Including financial information in the referral helps expedite the assessment
completion process. Personal and household income, asset amounts and other pertinent financial
information are required for the assessor to determine whether application to MaineCare as a potential
funding source is feasible. Household income is used to calculate cost sharing for some State funded
programs. At the time of the assessment, the assessor will verify any financial information submitted. If
the source of income is known but amount is not known, enter NK in amount column. If no financial
information is known check the Not Known box.
14. LEGAL GUARDIAN:
Check if consumer has a legal guardian. 0-No 1-Yes 2-Not Known.
Many long-term care consumers have a variety of legal arrangements such as durable powers of attorney
and guardianship. These legal arrangements may affect who makes the choice of where and what kind of
care the person will receive, as well as who needs to be involved in the assessment and who has access to
information. It is important for people working in the long-term care field to understand the subtle
differences between these different kinds of arrangements, in order to ensure that both consumer‟s right
of choice is preserved and that informed choices are made.
It is also important that referents, assessors and others, faced with a situation in which the person has a
guardian, ask to see the court papers that describe the scope of the guardianship. Either the
“Adjudication of Incapacity” or the “Letters of Guardianship” should be reviewed. These should be
made available by the guardian, but can also be obtained from the probate court. The guardianship
order may not allow the guardian to make decisions about long-term care and placement choices.
15. REFERRAL INFORMATION:
Check if consumer is aware of this referral that is being made for them. 0-No or 1-Yes. We expect most
consumers are informed of referral and what to expect.
16. VISUAL/HEARING:
Check if consumer has visual impairments 0-No or 1-Yes.
Check if consumer has hearing loss 0-No or 1-Yes.
17. COGNITION/BEHAVIOR
a. Cognitive Impairment: Check if consumer has cognitive impairment as noted by family members,
caregivers, or provider agency staff. 0-No or 1-Yes. Describe the level of cognitive impairment in the
comment section of the referral form to alert assessor to additional needs to be considered (i.e. having
someone else present at assessment).
b. Behavioral Problems: Check if consumer has behavioral problems as noted by family members,
caregivers, or provider agency staff. 0-No or 1-Yes. Describe any specific needs in the comment section
of the referral form.
18. ADVANCED DIRECTIVES: Federal law requires that people be told about their right to make
decisions about their health care choices. The medical record in the nursing facility or hospital setting
includes the necessary information to determine what category to check. AAA's have available a
comprehensive record of information on most of the people they serve. All health care providers are
required to ask people about their preferences and should be knowledgeable and comfortable in
discussing these basic issues. Review medical records, when available, for written documentation
verifying the existence and nature of these directives. Documentation must be available in the record for
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a directive to be considered current and binding. Check all items that apply and have supporting
documentation available.
a. Living Will: A document specifying applicant's preferences regarding measures used to prolong life
when there is a terminal prognosis. It may specify that no heroic measures are to be used to prolong
life when there is a terminal prognosis.
b. Do not resuscitate order: In the event of respiratory or cardiac failure, the person or family or legal
guardian has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods will
be used to attempt to restore respiratory or circulatory function.
c. Do not hospitalize order: A document specifying that person is not to be hospitalized even after
developing a medical condition that usually requires hospitalization.
d. Organ donation: Instructions indicating that person wishes to make organs available for
transplantation upon death.
e. Autopsy request: Document indicating that the person or family or legal guardian has requested that
an autopsy be performed upon death. [Note: The family must still be contacted prior to
performing the procedure.]
f. Feeding restrictions: Applicant or family or legal guardian does not wish the person to be fed by
artificial means (e.g., tube, intravenous nutrition) if unable to be nourished by oral means.
g. Medication restrictions: Applicant or family or legal guardian does not wish the person to receive
life-sustaining medications (e.g., antibiotics, chemotherapy) [Note: These restrictions may not be
applicable, however, when these medications are used to ensure the applicant's comfort.]
h. Other treatment restrictions: Applicant or family or legal guardian does not wish the person to
receive certain medical treatments. Examples include, but are not restricted to, blood transfusion,
tracheotomy, respiratory intubation, restraints. [Note: These restrictions may not relate to care
given for palliative reasons, such as reducing pain or distressing physical symptoms, such as
nausea or vomiting.]
i. None of Above: If none of the above directives apply or they cannot be verified by documentation in
the medical records, check None of Above.
19. CURRENT COMMUNITY CARE PLAN
This section communicates information to the assessing services agency about the current community
services being delivered to the consumer, the anticipated length of those services and the funding or
reimbursement for the services. Certain programs require medical eligibility and prior authorization. To
assure that service delivery is not duplicated the assessor benefits from knowing, prior to authorizing the
plan of care, the frequency and schedule for services currently in place. If the consumer is not currently
receiving a plan of care in the community check the 0-NA box for Not Applicable.
Provider: Enter the name of the provider who is currently delivering services to the consumer.
Service Category: Enter the appropriate code or acronym from the attached list to indicate the service
category that is currently being used to meet the consumer‟s needs.
Duration: Enter the Start Date and End Date (if known) for the current care plan that is now being
delivered.
Frequency: Enter the number of hours or visits being delivered and indicate this per month.
Funding Source: Enter the funding source using the attached codes for the programs that are paying for
this plan of care.
20. REFERRAL SOURCE: Enter the appropriate number for the source of this referral.
21. LOCATION AT TIME OF ASSESSMENT: Enter the corresponding number for the person‟s location
where the assessment is to be completed. If the person is in a hospital fill in the campus name or section
of the hospital and the patient‟s room number.
22. PROVIDER REFERRAL:
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a. Enter the referring provider agency, hospital or facility name.
b. Enter the contact name for this provider agency. This should be the name of someone who would
have any additional information if the assessing services agency had any questions about this referral.
c. Enter the telephone number of this contact person.
If this referral is not from a provider agency or facility, check off 0-NA in this box for Not Applicable.
23. PERSONAL/OTHER REFERRAL:
This section is for those referrals that come in from family members, caregivers, informal support
sources who are not affiliated with a provider agency or long-term care facility. If this referral is from a
provider agency check off 0-NA for Not Applicable.
a. Enter the name of the person making the referral.
b. Enter the name of person to be contacted regarding this referral if it differs from the referral name.
This should be the name of someone who would be most knowledgeable about this referral if the
assessing services agency had any further questions.
c. Enter the telephone number of the contact person.
24. ASSESSMENT TRIGGER: Select the option that matches this referral request.
1. Service Need: Referent requests an assessment based on the consumer‟s need for service. May be
used for any referral requesting a specific assessment for the programs listed in block #26. Referrals
for consumers on programs managed by Elder Independence of Maine (Private Duty Nursing/Personal
Care Services (PDN/PCS) for adults, Elderly and Adults with Disabilities HCB (Home and
Community Benefits), Home Based Care) must be requested by Elder Independence of Maine.
Programs managed by Alpha One (Consumer-directed Attendant Services (CDAS) and Physically
Disabled HCB) must be requested by Alpha One.
2. Reassessment due: Only applies to people with currently complete and valid assessments due to
expire, and reassessment is required to determine continued medical eligibility.
3. Significant Medical Change: Only applies to people with a currently complete assessment.
Indicators of significant change must be met. A significant change in status is defined as a major
change in the person‟s status that: is not self-limiting; impacts on more than one area of the person‟s
health status; and requires interdisciplinary review and/or revision of the care plan. A significant change
assessment may be requested if a change is consistently noted in two or more areas of decline, or two or
more areas of improvement.
For programs managed by Elder Independence of Maine or Alpha One, please contact them to
request a significant change reassessment. They will refer to the assessing services agency for a
reassessment.
4. Financial Change: Only applies to people with a currently complete assessment, for whom financial
eligibility because of income, assets, or funding has changed.
25. ASSESSMENT TYPE: Indicate whether this is an initial or reassessment.
Initial assessment (1): is the first assessment completed on a consumer triggered by a specific request.
Reassessment (2): A consumer has an existing valid assessment due to expire and requires reassessment
for determination of continued medical eligibility. A reassessment may also apply when a consumer
chooses to transfer from one specific program or funding source to another program or funding source. A
significant change in the consumer‟s condition, improvement or deterioration, may also trigger a
reassessment.
Date Due: Fill in the appropriate reassessment due date based on the length of time of the prior medical
determination. PAYMENT ends with the reassessment due date and will not continue without a
reassessment to determine continued medical eligibility for the current program.
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26. PROGRAM ASSESSMENT REQUESTED: Check only one from the following:
1. Long Term Care Advisory: Any person who requests an assessment for long-term care services at home,
in community or in a nursing facility.
Home and Community Care assessments: Select #1 – Long Term Care Advisory for consumers
seeking long-term care services in their home who are currently not receiving any services and for those
whose Medicare or MaineCare Home Health services are ending and they may need LTC services.
Nursing Facility Care: In order to comply with the State statute a preadmission LTC Advisory
assessment must be completed on every consumer admitted to a nursing facility prior to admission,
except when transferred from a hospital to SNF level of care under Medicare or other third party
payor. The consumer receives information regarding whether or not, based on the MED form, nursing
facility level of care is necessary. Within up to ninety (90) days of the assessment date (depending on
length of advisory validity determined at assessment) the consumer may choose another option for care
and have the assessment “UPDATED” to a MaineCare decision if the assessing services agency receives
notification from OIAS, that a MaineCare financial application for nursing facility level of care has been
filed. This is considered an Initial assessment and because it is advisory in nature there is no appeal
available. The consumer receives an advisory plan of care for community based services and may
or may not make a choice.
NOTE: Updates of Advisory assessments to NF MaineCare decisions will NOT occur until the consumer
enters the NF and the assessing services agency receives either a transfer form, fax or telephone referral
request from the NF. If prior to admission to the NF, the assessing services agency receives an OIAS/
LTC message form, the assessing services agency will complete the form with AP at home or hospital,
with eligibility as of the assessment date and return the completed LTC (122) form to OIAS. This alerts
OIAS that NF medical eligibility has been determined and OIAS will proceed with financial eligibility
determination. At admission to the NF, the original assessment is updated from advisory giving a 90
day reassessment date from the date of the original assessment. The assessing services agency will send a
LTC (122) message form to OIAS indicating the move from awaiting placement to NF admission, being
sure to complete the change in address section to the NF address.
Hospital to NF or home to NF admissions: Nursing facilities forward the transfer form to the assessing
services agency upon a consumer‟s admission. An RN in central office or the RN assessor will complete
the conversion assessment and return the converted background and outcome page to the Department
within five (5) days. Concurrently a new letter of eligibility that includes the eligibility start date and
reassessment date will be issued to the consumer. A copy of the “converted” assessment version (all
sections) and all other relevant paperwork will be forwarded to the nursing facility. A choice letter,
signed on the day of the assessment, will also be sent to the facility. Payment to the facility cannot begin
until the transfer form is received, financial eligibility for MaineCare has been approved and the awaiting
placement status is converted to admission status.
2. Adult Day Services: Any person who wants to access adult day services at a licensed facility must have
an assessment completed to determine functional eligibility for any programs receiving OES funding.
Assessing services agency or day services program may do assessment. If the assessment is completed by
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the assessing services agency, the assessment includes an Advisory plan of care and is forwarded to the
appropriate day services provider chosen by the consumer.
3. OES Independent Support Services (Homemaker): Consumers who want to access homemaker
services under the OES Independent Support Services program. Assessing services agency completes the
eligibility assessment. When the assessment is completed, it is forwarded to the Independent Support
Services (homemaker) provider.
4. MaineCare Day Health I, II, III: Current Community MaineCare member who wants access to adult
day health services reimbursed by MaineCare. Person must have Community MaineCare and attend a
MaineCare licensed/certified Adult Day Health Program for reimbursement to occur from the MaineCare
State Plan program. Assessments are completed by the assessing services agency. When the assessment
is completed by the assessing services agency, the completed MED form must be forwarded to the Adult
Day Health Services provider chosen by the consumer.
5. Consumer Directed PA I, II, III: For current MaineCare members who want to access the Consumer
Directed Attendant Services. The consumer applying must have a valid Community MaineCare card and
be deemed medically eligible and capable of hiring, directing, training, supervising and firing their PA.
The assessing services agency completes the assessment and the authorized plan of care. The completed
assessment is forwarded to Alpha One.
6. Home Based Care Program: Consumers 18 years and older who want to access the State funded home
based care program, care plan coordination by Elder Independence of Maine. Initial and reassessments
are conducted according to policy. Providers who believe a significant change or service need assessment
is needed MUST contact Elder Independence of Maine to authorize and request a reassessment.
7. Physically Disabled HCBS: For consumers determined medically eligible for nursing facility care who
choose to receive that level of care at home. Consumer must be able to self-direct personal care services.
The assessing services agency completes the assessment and the authorized plan of care. The completed
assessment is forwarded to Alpha One.
8. Elderly HCBS: Persons 60 years or older determined medically eligible for nursing facility care and
choose to receive that level of care at home. Providers who believe a significant change or service need
assessment is needed MUST contact Elder Independence of Maine to authorize and request a
reassessment.
9. Adults with Disabilities HCBS: Persons 18-59 years old determined medically eligible for nursing
facility care and choose to receive that level of care at home. Providers who believe a significant change
or service need assessment is needed MUST contact Elder Independence of Maine to authorize and
request a reassessment.
10. Private Duty Nursing - Levels I, II, III, VIII: Current MaineCare member, age 21 or older, who wants
to access community services of a RN, LPN, HHA, CNA, PCA. Providers who believe a significant
change or service need assessment is needed MUST contact Elder Independence of Maine to authorize
and request a reassessment.
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11. Adult Family Care Home: Medical Eligibility Determination (MED) assessment is no longer required
for admission to Adult Family Care Home. Adult Family Care Homes are residential style homes where
residential care services are provided for six or fewer people.
12. PDN – Level V: MaineCare member who is determined medically eligible for hospital level of care and
wants to receive that care in their home. Providers who believe a significant change or service need
assessment is needed MUST contact Elder Independence of Maine to authorize and request a
reassessment.
13. Nursing Facility Assessment: Assessment requested prior to admission to a nursing facility as a
MaineCare member or for a redetermination (reassessment) of medical eligibility for continued
MaineCare reimbursement. This could be triggered by service need, significant change or reassessment
due. NOTE: Consumers transferring from the hospital to SNF level of care that require MaineCare for
full reimbursement because Medicare or any other third party payor is not available MUST be assessed
and determined medically eligible prior to admission to the SNF unit or facility.
There are several categories of requests that are nursing facility assessments but fall under special funding or
policy parameters. The following are those NF assessment request types:
14. 20-day Medicare/MaineCare: Person enters nursing facility under the Medicare benefit and requires
nursing facility MaineCare financial assistance with the 20% copay and deductible beginning on day 21
of a skilled nursing facility stay. Valid eligibility classification is limited to the time period that
Medicare continues to pay for the 80% cost of stay. Assessments are completed only when the assessing
services agency has received notice from OIAS that a MaineCare application has been filed for nursing
facility MaineCare. This is considered an initial assessment. This is a time limited medical eligibility
determination up to no more than 80 days of Medicare or other third party coverage for SNF level of
care. Updates or conversions do not apply to this category of assessments. Please note that an Advisory
plan is not applicable for this type of assessment. NOTE: Consumers transferring from the hospital
to SNF level of care who require MaineCare for full reimbursement because Medicare or any
other third party payor is not available MUST be assessed and determined medically eligible
prior to admission to the SNF unit or facility.
15. Medicare to MaineCare: If a person wants to stay in the nursing facility at the end of the Medicare
benefit stay (up to 100 days maximum), an assessment must be completed to determine medical
eligibility for MaineCare to pay 100% for NF care. The assessing services agency must have received
notice from OIAS that a financial nursing facility MaineCare application has been filed or the consumer
must already be a nursing facility MaineCare member prior to the SNF stay. For members with
Community MaineCare, for whom an OIAS notice has not been received, who are requesting to stay in
the NF, the assessment will be considered an initial and the outcome will be Advisory.
16. 20-day copay to NF MaineCare: If a person wants to stay in the nursing facility at the end of the
Medicare benefit stay, when a 20 day Medicare/ MaineCare copay assessment has been completed, an
assessment must be completed to determine medical eligibility for MaineCare to pay 100% for NF care.
This is considered a reassessment because the initial assessment was completed on Day 20 of the
Medicare stay.
17. 30-day Community MaineCare: Community MaineCare provides up to 30 days of nursing facility care
without requiring that the member‟s financial eligibility be reviewed for nursing facility MaineCare
benefit. Eligibility is valid for only 30 days and the assessment expires unless the member has applied
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for a financial review. If notice is received from OIAS of the financial review, a conversion assessment
must be done to indicate continued medical eligibility. If a consumer appeals the outcome of an
assessment following a 30-day MaineCare eligibility period, MaineCare will NOT continue
reimbursement to the nursing facility during the appeal because nursing facility MaineCare was NOT
the reimbursement source. This assessment expires at the 30-day date. This 30-day end date does not
equate with reassessment date. If the assessing services agency receives notice from OIAS that the
consumer requested a financial change to NF MaineCare, the conversion of the original will be viewed
as an initial NF assessment.
18. Advisory nursing facility assessment to MaineCare Update: Person initially requests an assessment
for admission to a nursing facility. Advisory medical eligibility is determined and is valid for up to 90
days. If the assessor receives notice that a MaineCare financial application has been filed at OIAS, and
the consumer was determined medically eligible for NF, an update may be done if within advisory‟s
valid period (from 30 to 90 days as determined at time of assessment). If the consumer was denied
medical eligibility at the time of the Advisory assessment, a face-to-face reassessment, reimbursed by
MaineCare must be completed within 5 days of receipt of the LTC message form from OIAS.
19. Advisory Medicare to Private Pay nursing facility: If the person chooses to stay in the nursing facility
and private pay at the end of the Medicare or other third party payor SNF stay in the nursing facility, an
assessment must be completed to determine advisory medical eligibility, as mandated by State statute.
In these situations the mandated assessment has been deferred until the end of the SNF stay. In
order to comply with the State statute an Advisory assessment must be completed. If the
consumer chooses to remain in the NF or return home with services in place, after the SNF benefit
ends, an assessment MUST be completed. Medical eligibility is advisory and valid for up to 90 days,
as determined at time of assessment. No appeal to advisory determination. If the assessor receives
notice that a MaineCare financial application has been filed at OIAS, an update may be done if within
the advisory‟s valid time period.
20. Continuing Stay Review: Federal requirement for nursing facilities to review people quarterly for
“continued” medical need for nursing facility level of care. Nursing homes cannot terminate medical
eligibility. Nursing facility refers to assessing services agency for determination of medical eligibility
for current MaineCare members after notifying the consumer that continued medical eligibility is in
question. A copy of the continuing stay review notice issued to the resident by the facility is
required with this type referral.
21. Extraordinary Circumstances to Nursing Facility MaineCare: MaineCare currently paying for
nursing facility care on a person who is not medically eligible. The nursing facility requests an
assessment to determine medical eligibility based on a significant change in the member‟s condition.
The member‟s significant change MDS and most recent Quarterly MDS must be submitted with the
referral.
22. Katie Beckett: Providers are not required at this time to utilize this form to request an assessment.
An option for children under 18 to get services under MaineCare if they are determined medically
eligible for nursing facility, psychiatric hospital or hospital level of care.
23. Nursing Facility Private Duty Nursing: Providers are not required at this time to utilize this form
to request an assessment. For “0” to 21 year olds who are current MaineCare members and are
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determined medically eligible for nursing facility care that they receive at home or in the community
versus in a facility.
24. Independent Housing with Services Program: Consumer who wants access to Independent Housing
with Services. Independent Housing with Services provider or assessing services agency may do
assessment. If the assessment is completed by the assessing services agency as the outcome of a LTC
Advisory, the assessment includes an Advisory plan of care and is forwarded to the provider chosen by
the consumer.
25. BI - Brain Injury NF: People who have an acquired brain injury who are in need of specialized
services beyond nursing facility level of care. People must meet the nursing facility eligibility criteria
PLUS additional criteria. Please refer to Section 67 for additional criteria.
26. MaineCare Home Health: For consumers age 21 or older who are current MaineCare members and
who require prior authorization of MaineCare Home Health services according to Section 40.02-3D.
27. PDN Medication Services: Current severely mentally disabled MaineCare member who wants to access
Medication and Venipuncture Services only. Assessment is completed by PDN provider.
28. PDN Venipuncture Only: Current MaineCare member who wants to access PDN Venipuncture
services only. The individual requires only venipuncture services on a regular basis, as ordered by a
physician. Assessment is completed by PDN provider.
29. Consumer Directed HBC: Consumer who wants to access the State funded consumer-directed home
based care program. Consumer must be able to self-direct personal care services. Refer to Alpha One.
Alpha One will refer to Assessing Services Agency for completion of assessment.
30. Assisted Living (new 2009): Any person who wants to access assisted living facility services at a
licensed facility must have an assessment completed to determine functional eligibility for these services
funded through Office of Elder Services or MaineCare. Assessing services agency conducts the
assessment.
31. Residential Care (new 2009): Any person who wants to access residential care facility services at an
Appendix C residential care facility reimbursed through MaineCare funding must have an assessment
completed to determine functional eligibility for these services. Assessing services agency conducts the
assessment.
27. NF/HOSPITAL DATES: These dates are closely linked to the referral process and must be
completed to expedite timely completion of assessments.
a) Acute care denial date. This is the final date of payment by Medicare or other third party payor, for the
person‟s acute hospital care. This date must be provided to the Department‟s designated agent for
awaiting placement status to be determined and approved while an applicant is located in a hospital
setting. Fill in the blank or select “0” NA for not applicable. Example: TXZ hospital issued acute care
denial on 11/01/09. Fill in blank with November 1, 2009.
b) First Non-SNF date. This is the first day of nursing facility care not covered by Medicare or other third
party payor after skilled nursing facility (SNF) care. This is the date when another funding source must be
available to pay for the person to remain in the nursing facility. MaineCare, private pay or other third
party payors may be the source of reimbursement as of this date. The last funded Medicare date would be
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the day before this date. Fill in the blank or select “0” NA. Example: November 1, 2009 is the 100th day
and last day of Medicare /other third party payor date and November 2, 2009 is the first Non-SNF date.
c) Last day private pay. This is the last day that cost of nursing facility care will be covered by consumer‟s
funds (includes long-term care insurance). Fill in the blank or select “0” NA. In most cases this may be
an anticipated date from the NF as indicated by the family or other responsible party. It may also be a
date defined by OIAS on the LTC message form. Indicate if the date is anticipated: Last Day of private
pay: anticipated 11/01/09
d) Late notification date. If a nursing facility does not request a reassessment within the allotted time
frame required by policy, check “1” for Yes. This indicates to OMS and the provider that a timely
assessment /reassessment has not been requested according to policy requirements and payment may be
impacted. Lapse in eligibility dates will occur. Example: Reassessment due on November 1, 2009.
Provider requests reassessment on November 10, 2009. Check “1” for “yes” late notification. Check
“0” for No or Not Applicable when Late Notification does not apply.
e) Bed hold expired. If a person enters the hospital from a nursing facility and the 10 day bed hold
requested and allowed by policy expires, enter “1”- Yes or select “0” No if it has not expired or this is
NA. A bedhold expires after a nursing facility has requested the bedhold and the member remains in the
hospital for ten days (ten midnights), not returning to the nursing facility within this timeframe. Example:
Eligible MaineCare member admitted to hospital from NF on November 1, 2009. To be discharged back
to the NF as MaineCare on November 20th. Fill in box as “1” for “yes” bedhold expired. Consumer
should not return to the NF without an assessment being done if their bedhold has expired.
However, if the member spends 10 midnights in the hospital and returns to the NF prior to the 11th
midnight, the bedhold is not considered expired. Example: Member admitted to hospital on 11/01/09
from the NF, returns to the NF on 11/11/09, assessment does not have to be done.
f) Admission date. Fill in the appropriate date based on person‟s admission to the NF or the hospital. Fill in
the blank or select “0” NA for not applicable.
g) Discharge date. Fill in hospital discharge date as indicated by a physician order and documented in
person‟s medical record. If a delay in discharge occurs, the hospital must contact the assessing services
agency to prevent unnecessary assessments. Fill in the expected NF discharge date when the consumer
desires transfer to the community. If a consumer has been issued a discharge notice by the HHA, the
assessing services agency needs to be informed of that specific discharge date. The responsibility for
termination of Home Health services and the issuance of the discharge notification, as determined by the
Home Health Agency, remain the provider‟s responsibility. Fill in the appropriate discharge date as given
to the consumer in the discharge notice or select “0” NA for not applicable.
h) Home Health End date. Fill in the last funded date of MaineCare Home Health. Example: Current
certification period ends on November 30, 2009. Member now requires prior authorization. Fill in Home
Health end date 11/30/09.
28. PHYSICIAN: List name, address and phone number of applicant‟s physician.
29. EMERGENCY OR FAMILY CONTACT: Enter name and address of person who can be contacted if
needed to schedule the assessment or be present at the assessment. This contact person may also be
available in the event of emergency involving this applicant. List their telephone number and relationship
to the person. Also, check whether this contact is a legal guardian for the applicant.
30. COMMENTS: Enter any information pertinent to this referral that would aid the assessing services
agency in completion of this request for assessment. Also document any additional information about the
consumer, their individual situation, which should be noted. This space provides referral source the
opportunity to share information that contributes to a successful assessment process.
Office of Elder Services
11
10/30/2009
12
Referral Form Coding Sheet
#7 PRIMARY LANGUAGE - LANGUAGE LIST
Enter the code in #7 Primary Language box for the primary language spoken.
If the primary language spoken is not found in the following table, enter 3 for „Other‟ and specify the language
in space provided.
Code
Language
Code
0
0-English
30
German
59
Passamaquoddy
1
1-French
31
Greek
60
Pauluan
2
2-Spanish
32
Guamian
61
Penobscot Indian
3
3-Other
33
Gujarti
62
Persian
4
Acholi
34
Haitian
63
Polish
5
Afsomali
35
Hawaiian Samoan
64
Portugese
6
Albanian
36
Hebrew
65
Romanian
7
American Sign
37
Hindu
66
Russian
8
Amharic
38
Hungarian
67
Serbo Croatian
9
Apache
39
Italian
68
Shan
10
Arabic
40
Japanese
69
Somali
11
Bengali
41
Khmer
70
Swahili
12
Beti
42
Konkani
71
Swedish
13
Bohemian
43
Korean
72
Swiss German
14
Bosnian
44
Kuscien
73
Tagalog
15
Burmese
45
Lao
74
Taiwanese
16
Cambodian
46
Latvian
75
Tamil
17
Cantonese
47
Lebanese
76
Tarni
18
Caribbean English
48
Lithuanian
77
Telegu
19
Chamarro
49
Malayalam
78
Tewa Pueblo
20
Chinese
50
Maliseet
79
Thai
21
Czech
51
Mandarin
80
Tigrinya
22
Danish
52
Marathi
81
Turkish
23
Dari
53
Micmac
82
Ukrainian
24
Dinka
54
Nepali
83
Urdu
25
Dutch
55
Neur
84
Vietnamese
26
Farsi
56
Norwegian
85
Yiddish
27
Filipino
57
Nver
86
Yugoslavian
28
Finnish
58
Pashto
87
Zande
29
Gaelic
Office of Elder Services
12
Language
Code
Language
10/30/2009
13
#19 - CURRENT COMMUNITY CARE PLAN CODING SHEET
FUNDING SOURCE Enter the
payment code for the funding
source that is paying for current
services.
Program ID-Program Name
1-MaineCare Home Health
30-PDN Level I
2-PDN Level II
31-PDN Level III
36-PDN Level VIII
3-PDN Level V
4-PDN Level IV (NF Kids)
5-Elderly HCB
6-Adults with Disabilities HCB
SERVICE CATEGORY
Enter the appropriate code from
the following list to indicate the
service category being provided in
current Care Plan.
1 Administrative care management
2 Face-to-face care management
3 Adult day care
4 Personal care assistant (hour)
5 Personal care assistant (live-in)
6 Personal care assistant (night)
7 Homemaker
8 RN–visit
9 RN–hour
10 LPN–visit
11 LPN–hour
12 Home health aide–visit
13 Home health aide–hour
14 Certified nurse‟s aide–visit
15 Certified nurse‟s aide–hour
16 Physical therapy–visit
17 Physical therapy–hour
Office of Elder Services
7-Physically Disabled HCB
12-Adult Day Services
11-MaineCare Day Health – 1
32-MaineCare Day Health – 2
33-MaineCare Day Health – 3
10-Consumer Directed PA-1
34-Consumer Directed PA – 2
35-Consumer Directed PA - 3
29-Consumer Directed HBC
14-Home Based Care - 1
26-Home Based Care - 2
27-Home Based Care – 3
28-Home Based Care - 4
13-Independnt Support Services
18 Occupational therapy–visit
19 Occupational therapy–hour
20 Speech therapy–visit
21 Speech therapy–hour
22 Emergency response
23 Emergency response
installation
24 Psychiatric RN–visit
25 Master‟s social work–visit
26 Master‟s social work–hour
27 Social services
28 Transportation
29 Adult family care home
32 Family
33 Friend
34 Residential care
35 Independent living assessment
36 Certified occupational therapy
aide
8-Independent Housing
9-Katie Beckett
15-Title III
17-Adult Family Care Home
16-Assisted Living
20-Other
21-Medicare
22-3rd Party Payors (BC/BS,
Champus, VA, LTC Insurance)
23-Community MaineCare
24-Consumer‟s Funds
25-Nursing Facility
management
40 Environmental mods
41 Licensed speech therapy
assistant
42 Psychiatric medication services
43 Health assessment
44 Institutional respite-NF
45 Institutional respite-residential
care
46 Personal care assistant (visit)
47 Independent RN
48 Family Provider
49 RN Multiple
50 LPN Multiple
51-Care Management-PDN
52-Care Management-CDAS
53-Independent PT
54-Indepenednt OT
55-Independent Speech
37 Certified physical therapy aide
38 Meals on Wheels
39 Comprehensive care
13
10/30/2009
