2011 Eligibility Criteria for PCA Services

This quick guide summarizes the required fields on a Type B service agreement (SA) when recipient does not have dependency in 2 or more activities of daily living (ADL) and the 2011 DHS reassessment schedule (PDF) applies.

AGMT START DT

1. The SA start date is the same as the ASSESSMENT DATE on AHC1 following an initial assessment.
2. The SA start date is the first day of the month following the end date of the current service agreement following a reassessment.

AGMT END DT

Enter the SA end date as the last day of the month.

RECIP ID

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

DOB

Enter the recipient’s birth date in MMDDYYYY format.

AUTH SIG (Y/N)

Type a Y (yes) or N (no) to indicate if the assessor has signed the DHS-3244 form.

SACTAD NBR

Leave the SACTAD NBR field blank. Entry is mandatory for tribal agencies ONLY.

RESP PARTY (Y/N)

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

LIVES WITH RESP PARTY (Y/N)

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

RESP PARTY NAME

Enter first and last name of the responsible party.

FISCAL INT (Y/N)

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

PROC and MOD1-4 fields

1. Enter procedure code T1019 with no modifier for PCA.
2. Enter a line for supervision of PCA using procedure code/modifier T1019 UA.

START/END DT fields

1. Enter one line for PCA with start and end dates the same as the SA start and end dates following an initial assessment.
2. Enter one or two line for PCA with start and end dates within the SA start and end dates following a reassessment.
3. Enter one line for supervision of PCA with start and end dates the same as the SA start and end date.

REQ RATE/UNIT

Enter the current allowed dollar amount per unit.

REQ TOT UNITS

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

PROV NBR

1. Enter the provider’s NPI (National Provider Index) number or the UMPI (Unique Minnesota Provider Index) number.
2. Enter the DHS provider number A342517700 in the PROV NBR field when a recipient has not selected a provider. Exception codes 241, 412 and 420 post and MMIS automatically routes the SA to DHS for review when the DHS provider number is used.

SHR

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

FREQ

1. Enter frequency code 1 (daily-standard PCA) or 5 (flexible use) on the T1019 line.
2. Enter frequency code 3 (monthly) or 5 (flexible use) on the T1019 UA line.

PHONE

Enter the phone number of the assessor.

SPRVSN NURSE

Enter the last and first name of the assessor.

ASSESSMENT DATE

Enter the date of the assessment.

PCA CD

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

PC SUPERVISION CD

Enter an X in the CD field for supervision of PCA.

DIAGNOSIS 1

Enter the 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 an 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 the referral-completed field to indicate that the assessor made referral(s) for other services.
2. Enter N/A (not applicable) when no referral for other services is required.

EN

1. Enter an X in the EN field if the 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 the provider owns or controls housing field.

ADDITIONAL COMMENTS

1. Document the Units/day of PCA, flexible use split and PCA Choice provider.
2. Document the recommended PCA units/day when EN applies to recipient’s home care rating.
3. Document the name of second responsible party when there is more than one responsible party.
4. Add date that the assessor referred the person to other services.
5. Document the assessor's reason for HHA or PDN referral with PCA.
6. Date and initial all comments.

Date and initial all comments.

Date and initial all comments.