Page 2013

West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 88 Chapter 24 Long Term Care

24.12.3 ESTABLISHING RETROACTIVE MEDICAL NECESSITY USING PHYSICIAN’S PROGRESS NOTES OR ORDERS This procedure is used only for backdating eligibility for nursing facility care when no PAS exists for the period for which payment of services is requested. The progress notes or orders cannot be used to change an existing PAS which does not certify need for nursing facility care. Eligibility may only be backdated up to three months prior to the month of application. In certain circumstances, which may be beyond the control of the client or his authorized representative, a client may be admitted to a Medicaid-certified nursing facility without a PAS. When this occurs and the client applies for Medicaid and payment of nursing facility services for a prior period, the Worker may obtain and use the physician’s progress notes or orders in the client’s medical records to establish medical need. A valid PAS for current eligibility must still be obtained. This information is obtained from the nursing facility and the facility may request that the physician add such notes to the client’s records. These records may also be used when application is made and payment requested for a deceased client when no valid PAS was completed. The Worker must record the reason for the use of the progress notes or orders in case comments.

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Page 2013

Official source

West Virginia Income Maintenance Manual Chapter 24

West Virginia Income Maintenance Manual Page 88 Chapter 24 Long Term Care

24.12.3 ESTABLISHING RETROACTIVE MEDICAL NECESSITY USING PHYSICIAN’S PROGRESS NOTES OR ORDERS This procedure is used only for backdating eligibility for nursing facility care when no PAS exists for the period for which payment of services is requested. The progress notes or orders cannot be used to change an existing PAS which does not certify need for nursing facility care. Eligibility may only be backdated up to three months prior to the month of application. In certain circumstances, which may be beyond the control of the client or his authorized representative, a client may be admitted to a Medicaid-certified nursing facility without a PAS. When this occurs and the client applies for Medicaid and payment of nursing facility services for a prior period, the Worker may obtain and use the physician’s progress notes or orders in the client’s medical records to establish medical need. A valid PAS for current eligibility must still be obtained. This information is obtained from the nursing facility and the facility may request that the physician add such notes to the client’s records. These records may also be used when application is made and payment requested for a deceased client when no valid PAS was completed. The Worker must record the reason for the use of the progress notes or orders in case comments.