AGMT START DT

Enter SA start date. SA start date is the assessment date in the ASSESSMENT DATE field on AHC1.

AGMT END DT

Enter SA end date. SA end date is the assessment date.

RECIP ID

Enter recipient’s PMI (Person Master Index) number.

DOB

Enter recipient’s birth date in MMDDYYYY format.

AUTH SIG (Y/N)

Type Y (yes) or N (no) to indicate assessor signed the PCA Assessment and Service Plan (DHS-3244).

SACTAD NBR

1. Counties leave the SACTAD NBR field blank.

2. Tribal agencies enter tribal number/identifier in the SACTAD NBR field. This is mandatory.

RESP PARTY (Y/N)

Enter Y (yes) or N (no) to indicate if recipient has a responsible party.

LIVES WITH RESP PARTY (Y/N)

Enter Y (yes) or N (no) to indicate if recipient lives with responsible party.

RESP PARTY NAME

Enter first and last name of responsible party.

FISCAL INT (Y/N)

Enter Y (yes) or N (no). Fiscal intermediary is required when provider is a PCA Choice Provider.

PROC and MOD1-4 fields

1. Enter one line using procedure code T1019 for denial of PCA services.

2. Do not enter a line for supervision of PCA.

START/END DT fields

Enter one line for PCA. Start and end dates are the same as the SA start and end dates in the AGMT START/END DT fields on the ASA1 screen.

REQ RATE/UNIT

Enter current allowed dollar amount per unit.

REQ TOT UNITS

Leave requested total units fields blank.

PROV NBR

1. Enter provider’s NPI (National Provider Index) number or the UMPI (Unique Minnesota Provider Index) number.

2. Enter DHS provider number A342517700 when a recipient has not selected a provider.

SHR

Enter Y or leave shared services field blank.

FREQ

Enter frequency code 1 (daily-standard PCA) or 5 (flexible use).

RSN CD

Enter appropriate reason code to prompt MMIS to add legal notice language to the service agreement letters for denial.

PHONE

Enter phone number of the assessor.

SPRVSN NURSE

Enter last and first name of the assessor.

ASSESSMENT DATE

Enter date of the assessment in MMDDYY format.

BEGIN DATE and END DATE

Leave blank. MMIS auto-populates begin and end date fields.

PCA CD

Enter X in the CD field in front of PC to indicate PCA.

DIAGNOSIS 1

Enter recipient’s primary diagnosis ICD-9-CM code.

DIAGNOSIS 2 and DIAGNOSIS 3

Enter second and third diagnosis code when information is available.

CD fields

1. Enter X in assessment CD (code) fields to indicate needed activity.

2. Leave CD fields blank when activity does not apply.

REF COMP

1. Enter Y (yes) in referral-completed field to indicate assessor made referral(s) for other services.

2. Enter N/A (not applicable) when no referral for other services is required.

EN

1. Enter X in the EN field if recipient is on a ventilator a minimum of six hours per day for a minimum of 30 days.

2. Leave EN field blank when EN does not apply.

PROV OWN/CTRL

Enter Y (yes), N (no) or U (uncertain) in the provider owns or controls housing field.

ADDITIONAL COMMENTS

1. Document effective date and reason for denial of PCA services.

2. Document when recipient declines PCA services.

3. Document home care rating, units/day, flexible use split and/or if PCA Choice when recipient declines PCA services.

4. Document date the county, public health agency or tribe received request for initial assessment.

5. Document provider owner-controlled housing when applicable.

6. Date and initial all comments.

1. Document recipient declined PCA services when applicable.

2. Document reason for denial of PCA services.

3. Date and initial all comments.

1. Document recipient declined PCA services when applicable.

2. Document reason for denial of PCA services.

3. Date and initial all comments.

AGMT START DT

Enter new SA start date as first day of the month following current SA end date.

AGMT END DT

Enter SA end date as last day of the month.

RECIP ID

Enter recipient’s PMI (Person Master Index) number.

DOB

Enter recipient’s birth date in MMDDYYYY format.

AUTH SIG (Y/N)

Type Y (yes) or N (no) to indicate assessor signed the PCA Assessment and Service Plan (DHS-3244) form.

SACTAD NBR

Counties leave the SACTAD NBR field blank.

Tribal agencies enter tribal number/identifier in the SACTAD NBR field. This is mandatory.

RESP PARTY (Y/N)

Enter Y (yes) or N (no) to indicate recipient has a responsible party.

LIVES WITH RESP PARTY (Y/N)

Enter Y (yes) or N (no) to indicate recipient lives with responsible party.

RESP PARTY NAME

Enter first and last name of responsible party.

FISCAL INT (Y/N)

Enter Y (yes) or N (no). Fiscal intermediary is required when provider is a PCA Choice Provider.

PROC and MOD1-4 fields

If you finalize (enter, approve and save) the new SA 15 or more calendar days prior to the end date of the current SA do not enter a T1019 U5 line for reduction of PCA. 15 calendar days assures a full 10 business days for the mailing and receipt of the notice.
You must enter the appropriate reason code to meet legal requirements.

1. Enter two lines for PCA as you would for reassessment or service update.

2. Enter reason code 542 on the first T1019 line to add legal 10-day notice of reduction language to the SA letters.

3. Enter one line for supervision of PCA using procedure code/modifier T1019 UA.

If you finalize (enter, approve and save) the new SA less than 15 calendar days prior to the end date of the current SA enter one line. T1019 U5 for reduction and two lines for PCA.

1. Enter one line using procedure code/modifier T1019 U5 for notice of reduction line. MMIS automatically enters reason code 542 on the T1019 U5 line.

2. Enter remaining PCA lines using procedure code T1019.

3. Enter one line for supervision of PCA using procedure code/modifier T1019 UA.

START/END DT fields

Start date on the T1019 U5 line is the day after the end date of the current SA. Calculate the end date for the T1019 U5 line. Count 10 business days forward from the day you finalize (enter, approve and save) the new SA and enter that date in the T1019 U5 line END DT field. MMIS automatically enters reason code 542 on T1019 U5 line.

Start date on the first flexible use PCA line is the day following the end date of the PCA notice of reduction (T1019 U5) line.

End date on the first PCA line following the T1019 U5 line is always the last day of the month. The first PCA line will be less than 6 months because of the PCA notice of reduction line.

Start date on the second flexible use PCA line is always the first day of the month following the end date of the first PCA (T1019) line.

End date on the second PCA line is always the last day of the month. Enter a full six calendar months on the second PCA line.

Start and end dates on the supervision of PCA line must match the SA start and end dates.

REQ RATE/UNIT

Enter current allowed dollar amount per unit.

REQ TOT UNITS

Enter requested total number of units for the line date span:

PROV NBR

Enter provider’s NPI (National Provider Index) number or UMPI (Unique Minnesota Provider Index) number.

SHR

1. Enter Y or leave shared services field blank on PCA lines.

2. Leave field blank on supervision line.

FREQ

1. Enter frequency code 1 (daily-standard PCA) or 5 (flexible use) on T1019 U5 and T1019 lines.

2. Enter frequency code 3 (monthly) or 5 (flexible use) on T1019 UA line.

RSN CD

Leave reason code blank on T1019 U5 line. MMIS auto-populates RSN CD field on T1019 U5 (PCA NOTICE OF REDUCTION) line with reason code 542 to add legal 10-day notice of reduction language to the SA letters.

Enter reason code 542 if finalizing new SA in MMIS 15 or more calendar days prior to the end date of the current SA and there is no line for T1019 U5.

PHONE

Enter phone number of assessor.

SPRVSN NURSE

Enter last and first name of assessor.

ASSESSMENT DATE

Enter date of assessment in MMDDYY format.

BEGIN DATE and END DATE

1. Enter SA begin date as first day of the month following the end of the current SA.

2. Enter SA begin date as last day of the month.

MMIS populates these fields for one year if left blank. MMIS posts an exception code. Assessment date is equal to or up to 60 days prior to the AGMT START DT on ASA1.

PCA CD

Enter X in CD field in front of PC to indicate PCA.

PC SUPERVISION CD

Enter X in CD field in front of PC Supervision for supervision of PCA.

DIAGNOSIS 1

Enter recipient’s primary diagnosis ICD-9-CM code.

DIAGNOSIS 2 and DIAGNOSIS 3

Enter second and third diagnosis code when information is available.

CD fields

1. Enter X in assessment CD (code) fields to indicate needed activity.

2. Leave CD fields blank when activity does not apply.

REF COMP

1. Enter Y (yes) in referral-completed field to indicate assessor made referral(s) for other services.

2. Enter N/A (not applicable) when no referral for other services is required.

EN

1. Enter X in the EN field if the recipient is on a ventilator a minimum of six hours per day for a minimum of 30 days.

2. Leave EN field blank when EN does not apply.

PROV OWN/CTRL

Enter Y (yes), N (no) or U (uncertain) in provider owns or controls housing field.

ADDITIONAL COMMENTS

1. Document effective date and reason for reduction of PCA services.

2. Document home care rating and PCA Units/day on current SA used for T1019 U5 notice of reduction line on this SA.

3. Document name of second responsible party when there is more than one responsible party.

4. Document date that county, public health agency or tribe received the request from provider for reassessment.

5. Date and initial all comments.

1. Document reason for reduction of PCA services.

2. Date and initial all comments.

1. Document reason for reduction of PCA services.

2. Date and initial all comments.

AGMT START DT

Enter new SA start date as first day of the month following current SA end date.

AGMT END DT

If you finalize (enter, approve and save) the new service agreement (SA):

Count 15 calendar days from the date you finalize (enter, approve and save) the new SA. 15 calendar days assures a full 10 business days for the mailing and receipt of the notice.

You must enter the appropriate reason code to meet legal requirements.

RECIP ID

Enter recipient’s PMI (Person Master Index) number.

DOB

Enter recipient’s birth date in MMDDYYYY format.

AUTH SIG (Y/N)

Type Y (yes) or N (no) to indicate assessor has signed PCA Assessment and Service Plan (DHS-3244).

SACTAD NBR

1. Counties leave the SACTAD NBR field blank.

2. Tribal agencies enter SACTAD NBR (mandatory for tribal agencies ONLY).

RESP PARTY (Y/N)

Enter Y (yes) or N (no) to indicate recipient has a responsible party.

LIVES WITH RESP PARTY (Y/N)

Enter Y (yes) or N (no) to indicate he recipient lives with responsible party.

RESP PARTY NAME

Enter first and last name of responsible party.

FISCAL INT (Y/N)

Enter Y (yes) or N (no). Fiscal intermediary is required when provider is a PCA Choice Provider.

PROC and MOD1-4 fields

1. Enter one line using procedure code T1019 for notice of termination.

2. Enter one line for supervision of PCA using procedure code/modifier T1019 UA.

START/END DT fields

1. Enter line start and end dates. Dates are the same as the SA start and end dates in the AGMT START/END DT fields on the ASA1 screen.

2. Enter start and end dates for PCA supervision. Dates are the same as the SA start and end dates.

REQ RATE/UNIT

Enter current allowed dollar amount per unit.

REQ TOT UNITS

1. Enter requested total number of units for line date span.

2. Multiply units/day assessed on current SA times the number of days on T1019 line on new SA.

PROV NBR

Enter provider’s NPI (National Provider Index) number or UMPI (Unique Minnesota Provider Index) number.

SHR

1. Enter Y or leave shared services field blank on PCA lines.

2. Leave field blank on supervision line.

FREQ

1. Enter frequency code 1 (daily-standard PCA) or 5 (flexible use) on T1019 line.

2. Enter frequency code 3 (monthly) or 5 (flexible use) on T1019 UA line.

RSN CD

Enter reason code 543 to prompt MMIS to add legal 10-day notice of termination of PCA services language to service agreement letter.

PHONE

Enter phone number of assessor.

SPRVSN NURSE

Enter last and first name of assessor.

ASSESSMENT DATE

Enter date of assessment in MMDDYY format.

BEGIN DATE and END DATE

1. Enter SA begin date as first day of the month following the end of the current SA.

2. Enter SA begin date as last day of the month.

MMIS populates these fields for one year if left blank. MMIS posts an exception code. Assessment date is equal to or up to 60 days prior to the AGMT START DT on ASA1.

PCA CD

Enter X in CD field in front of PC to indicate PCA.

PC SUPERVISION CD

Enter X in CD field for supervision of PCA.

DIAGNOSIS 1

Enter recipient’s primary diagnosis ICD-9-CM code.

DIAGNOSIS 2 and DIAGNOSIS 3

Enter second and third diagnosis code when information is available.

CD fields

1. Enter X in assessment CD (code) fields to indicate needed activity.

2. Leave CD fields blank when activity does not apply.

REF COMP

1. Enter Y (yes) in referral-completed field to indicate assessor made referral(s) for other services.

2. Enter N/A (not applicable) when no referral for other services is required.

EN

1. Enter X in EN field if recipient is on a ventilator a minimum of 6 hours per day for a minimum of 30 days.

2. Leave EN field blank when EN does not apply.

PROV OWN/CTRL

Enter Y (yes), N (no) or U (uncertain) in provider owns or controls housing field.

ADDITIONAL COMMENTS

1. Document effective date and reason for termination of PCA services.

2. Document home care rating and PCA units/day on current SA used for notice of termination period on this SA.

3. Date and initial all comments.

1. Document reason for termination of PCA services.

2. Date and initial all comments.

1. Document reason for termination of PCA services.

2. Date and initial all comments.