Notice of Denial of PCA Services

This quick guide summarizes the required fields on a Type B service agreement (SA) for denial of PCA services when the recipient does not meet PCA access criteria or declines PCA services following and initial assessment.

AGMT START DT

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

AGMT END DT

SA end date is the same as the assessment date.

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 PCA Assessment and Service Plan (DHS-3244).

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 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

Line start and end dates are the same as the SA start and end dates in the AGMT START/END DT fields on the ASA1 panel.

REQ RATE/UNIT

Enter the current allowed dollar amount per unit.

REQ TOT UNITS

Leave the requested total units fields blank.

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 when a recipient has not selected a provider.

SHR

Enter Y or leave the shared services field blank.

FREQ

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

RSN CD

Enter the appropriate reason code to trigger MMIS to add legal notice language to the service agreement letters for denial of PCA services.

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 in MMDDYY format.

BEGIN DATE and END DATE

MMIS auto-populates begin and end date fields.

PCA CD

Enter an X in the CD field in front of PC to indicate 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 effective date and reason for denial of PCA services.
2. Document when recipient declines PCA services.
3. Document the home care rating, Units/day, flexible use split, if PCA Choice when recipient declines PCA services.
4. Document the date that the county, public health agency or tribe received the request for initial assessment.
5. Document provider owner controlled housing when applicable.
6. Date and initial all comments.

1. Document that the recipient has declined PCA services when applicable.
2. Document the reason for denial of PCA services.
3. Date and initial all comments.

1. Document that the recipient declined PCA services when applicable.
2. Document the reason for denial of PCA services.
3. Date and initial all comments.