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West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 83 Chapter 24 Long Term Care

24.12 ESTABLISHING APPLICANT AS AGED, BLIND, OR DISABLED AND THE MEDICAL NECESSITY FOR NURSING FACILITY CARE 24.12.1 ESTABLISHING MEDICAID CATEGORICAL RELATEDNESS When the applicant for nursing facility services is not a Medicaid client under a full Medicaid coverage group, categorical Medicaid eligibility and financial eligibility must be established for the Nursing Facility coverage group or the SSI-Related/Monthly Spenddown group. Disability or blindness, when not already established by the receipt of Retirement, Survivors, and Disability Insurance (RSDI) or Railroad Retirement benefits based on disability, must be established by the Medical Review Team (MRT). All procedures in Chapter 13 for an MRT referral for the appropriate coverage group are applicable, and a presumptive approval may be made according to the guidelines in Chapter 13. The Pre-Admission Screening (PAS) does not by itself establish disability. However, a copy of the PAS may be submitted to the MRT as medical information. 24.12.2 ESTABLISHING MEDICAL NECESSITY, THE PAS 24.12.2.A General Requirements Before payment for nursing facility services can be made, medical necessity must be established for all clients. The PAS is the tool used for this purpose. The PAS is signed by a physician and then evaluated by a medical professional working with the State’s contracted level of care evaluator. The PAS is valid for 60 days from the date the physician signs the form, which is the only date used for establishment of medical necessity. The 60-day validity period applies, regardless of the reason for the completion. See below for situations when a PAS is not completed and payment for nursing facility care is requested for a prior period.