Effective Date: 
4/2017

Documents

Instructions

Updated: 4/2017

Purpose

Form 1013 is used when the nursing facility (NF) wants to change a negative Preadmission Screening and Resident Review (PASRR) Level One (PL1) that has already been submitted to the Texas Medicaid & Healthcare Partnership (TMHP) Long Term Care Portal. The Texas Health and Human Services Intellectual and Developmental Disability (IDD) PASRR unit is responsible for reviewing, approving or denying requests to change a negative PL1 to a positive PL1. Only requests received on Form 1013 will be reviewed. If approved, the NF (not IDD PASRR) will enter a new positive PL1 in the Long Term Care Portal.

When to Prepare

The NF may submit a request for authorization to enter a new positive PL1 to correct a negative PL1 for individuals who are currently admitted to the facility. The following situations are appropriate for submitting Form 1013:

  • Following a review of an individual’s current PL1 record, the NF may determine that PL1 sections C0100, C0200 and/or C0300 sections on the form were filled out incorrectly or that the individual’s diagnosis has changed.
  • Following a survey that determined the PL1 is incorrect or needs review.

Note: All requests to enter a new negative PL1 to inactive a positive PL1 will be denied.

Instructions

  • Complete all required information in each section of the form and make sure the information is legible. Forms will be denied and returned to the NF if information is not complete or legible.
  • Include an accurate area code and telephone number, fax number and email address for the primary contact.
  • Indicate whether the request is related to an IDD, mental illness (MI) or dual diagnosis.
  • Indicate if the individual’s primary diagnosis is Dementia/Alzheimer’s.
  • Provide a brief summary explaining the reason for the requested change.
  • Attach appropriate documentation to support the request.
  • Include any diagnosis that may have been added or is on the current Minimum Data Set (MDD) forms that require the current negative PL1 to be reviewed and changed.
  • Do not use abbreviations for any medical diagnosis or terminology.
  • Do not submit a request for individuals who are no longer in the facility.
  • Fax this form to the IDD PASRR Unit at 512-438-2180.

The IDD PASSR Unit will review Form 1013 and make a determination to approve or deny the request. The IDD PASRR review process includes:

  • confirming all sections of the form are completed properly;
  • reviewing supporting documentation and determining if more information is needed;
  • reviewing the individual’s record in the Long Term Care Portal to support the request, if appropriate;
  • approving or denying the request and faxing the form back to the NF; and
  • monitoring approved requests to ensure changes are implemented by the NF.

If the request is approved, the NF will enter a new positive PL1 in the Long Term Care Portal. If the request is denied, the NF may provide additional information to support the change and can resubmit Form 1013.

For questions related to the form or the PL1 change request process, contact the PASRR Unit at 1-855-435-7180 or by email to PASRR.Support@hhsc.state.tx.us.

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