Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd. • Oklahoma City, OK 73105
(405) 521-3646 • Fax (405) 521-6684 • Internet: www.okdhs.org
317:35-19-2. Nursing Facility (NF) program medical eligibility determination

Revised 6-25-04

     The OKDHS area nurse, or nurse designee (OHCA, LOCEU makes some determinations when PASRR is involved), determines medical eligibility for nursing facility (NF) services based on the Long Term Care (LTC) nurse's UCAT, Part III assessment of the client's needed level of care, the outcome of the Level II Preadmission Screening and Resident Review (PASRR), if completed, and professional judgment.  Refer to OAC 317:35-19-7.1(3) for nursing facility level of care medical eligibility requirements.

  • (1) When NF care services are requested prior to admission, the same rules related to medical eligibility determination identified in OAC 317:35-17-5 for ADvantage services are followed.
  • (2) The LTC nurse submits the UCAT, Part III, the Long-Term Care Preadmission Screen form (PASRR), and the NF request for assessment to the area nurse, or nurse designee, for medical eligibility determination.
  • (3) PASRR requirements are identified in OAC 317:35-19-8 and 317:35-19-9.
  • (4) When it is not possible for the UCAT assessment to be completed prior to admission, the NF is responsible for notifying the OKDHS of the admission.  Notification will be by mailing or by faxing the OKDHS form ABCDM-83 (new form number 08MA083E) (Notification Regarding Patient In A Nursing Facility, Intermediate Care Facility for the Mentally Retarded or Hospice), OKDHS form ABCDM-96 (new form number 08MA084E) (Management of Recipient's Funds), and OKDHS form ABCDM-83-A (new form number 02AG001E), Request for Title XIX Nursing Assessment, to the local OKDHS county office.  Upon receipt, the OKDHS county office processes the ABCDM-83 (new form number 08MA083E), ABCDM-96 (new form number 08MA084E), and the ABCDM-83-A (new form number 02AG001E) and completes and forwards the OKDHS form ABCDM-37D (new form number 08MA038E) (Notice Regarding Financial Eligibility) to the NF.  Identified sections of the UCAT reflecting the domains for meeting medical criteria are completed for applicants residing in the NF at the time of assessment.  The area nurse, or nurse designee, determines the date of medical eligibility and records it on the system based on the date of financial eligibility.  The facility is responsible for performing the PASRR Level I screen and consulting with staff of the OHCA as to whether a need exists for a Level II screen.  The LTC nurse will conduct the assessment visit within 15 working days of request for assessment if the individual's needs are included in an active ABCDM case.  If the individual's needs are not included in an active ABCDM case, the assessment is conducted within 20 working days of the date of the signed application.  The LTC nurse forwards the completed preadmission screen, the ABCDM-83-A (new form number 02AG001E), and the UCAT, Part III (new form number 02HM003E) to the area nurse or nurse designee.
  • (5) The area nurse, or nurse designee, will evaluate the PASRR Level I screen and the UCAT, Part III (new form number 02HM003E) and consult with staff of the OHCA as to whether a need exists for a Level II screen as necessary.
  • (6) The area nurse, or nurse designee, will evaluate the UCAT, Parts I (new form number 02HM001E) and III (new form number 02HM003E), the Long-Term Care Preadmission Screen form and the physician's diagnosis to determine whether the applicant meets the medical eligibility criteria for NF level of care. Individuals may be medically certified for NF level of care for various lengths of time depending upon the needs of the client.  The area nurse, or nurse designee, enters the medical eligibility decision, and when required, the medical certification review date on the system within ten working days.  A medical eligibility redetermination is not required when a client is discharged from the NF for a period not to exceed 90 days and the original certification is current.
  • (7) If the LTC nurse recommends NF level of care and the client is determined by the area nurse, or nurse designee, not to be medically eligible for NF level of care, the LTC nurse can submit additional information to the area nurse, or nurse designee.  When necessary, a visit by the LTC nurse to obtain additional information can be initiated at the recommendation of the area nurse, or nurse designee.
  • (8) Categorical relationship must be established for determination of eligibility for NF services.  If categorical relationship to disability has not already been established, the worker submits the same information described in OAC 317:35-5-4(2) to the LOCEU to request a determination of eligibility for categorical relationship.  LOCEU renders a decision on categorical relationship to the disabled using the same definition used by SSA.  A follow-up with the SSA by the OKDHS worker is required to be sure that the SSA disability decision agrees with the decision of LOCEU.
Last Updated:  10/25/2008