The Pre-Admission Screening and Resident Review (PASRR) is a federally required screening of any individual who applies to or resides in a Medicaid-certified nursing facility, regardless of the source of payment.
This requirement was enacted to ensure individuals with serious mental illness (SMI), intellectual or developmental disabilities (I/DD) and/or related conditions (RC) receive appropriate placement and services.
- A Level I identification screening must be performed before anyone can be admitted to any Medicaid-certified nursing facility.
- When the Level I screening indicates the possibility of SMI, I/DD or RC, a Level II, in-depth evaluation must be performed to assess for nursing facility placement and for potential specialized care needs of the individual.
- PASRR screenings must also be provided for previously admitted individuals who have demonstrated a SMI, I/DD and/or RC significant change in condition.
NC Medicaid uses an Internet-based screening tool to manage the PASRR Program. The North Carolina Medicaid Uniform Screening Tool (NCMUST) user interface allows referring and admitting agencies to communicate and manage PASRR screens in a self-service application. NCMUST uses an automated decision service to establish the appropriate PASRR level. The assigned PASRR authorization is usually generated in seconds and is viewable in NCMUST. If manual review of the screen is required, the screen is routed to a queue monitored by NC Medicaid PASRR nurse consultants. The NC Medicaid PASRR nurse consultants can then communicate back to the originator of the screen (screener) as needed to make a clinical decision.
How do I register to submit PASRR screenings?
For detailed instructions on how to register please contact our NC PASRR helpdesk at 919-813-5603 (Direct) / 888-245-0179 (Toll Free).
How do I update my information on the NC Medicaid Uniform Screening Tool (NC MUST) website?
To update demographic information please contact our NC MUST helpdesk at 919-813-5603 (Direct) / 888-245-0179 (Toll Free).
How do I correct mistakes on a PASRR screening form?
Corrections can only be made to the screening form prior to submission. Once a screening form has been submitted corrections cannot be made and a new form will be required.
What is a USP ID?
A USP ID or Uniform Screening Program Identification is a unique identifying number assigned by the NC MUST application for an individual being screened. Unlike the MUST ID an individual applicant only receives one USP ID.
When would I require a USP ID?
If the applicant does not have a SSN, you are required to contact the NC PASRR helpdesk to obtain a USP ID which will be used in place of a SSN. You may reach the Helpdesk directly by calling 919-813-5603 or toll free at 888-245-0179.
What do we do about screens in a running status?
If you have submitted a screening form into NC MUST and the status is shown as "running" then please call the NC PASRR helpdesk at 1-888-245-0179 (Toll free)/ 1-919-813-5603 (Local) for a status reset.
How do we get PASRR requests expedited?
PASRR requests are not expedited. Authorizations are reviewed on a first-come, first-serve basis.
What do the PASRR authorization codes mean?
PASRR authorizations determine approval, denial along with corresponding time frames and/or restrictions for placement into a Skilled Nursing Facility.
Does a 30-day PASRR request require a physician’s signature?
All PASRR request for a 30-day time-limited categorical stay in the skilled nursing facility requires the signature of an attending physician from the discharging hospital.
Can a 30-day authorization be given for anyone?
Thirty-day time-limited PASRR authorizations are only given to individuals that would otherwise require a full Level II evaluation but have been exempted through physician certification. These authorizations are only for rehabilitative services at a Skilled Nursing Facility (SNF).
Federal law (42 CFR 483.128) mandates the provision of Level I screens for all applicants to Medicaid-certified nursing facilities to identify residents with serious mental illness (SMI), intellectual or developmental disabilities (I/DD) or a related condition (RC). It is the responsibility of the screener to initiate the Level I screen via NCMUST prior to admission.
For residents with no evidence or diagnosis of SMI, I/DD or RC, an initial Level I screen remains valid unless there is a significant change in condition.
A Level I identification screen is designed to identify individuals with SMI, I/DD or RC using specific diagnostic and functional questions. A Level I screen and, when required, a Level II evaluation is performed prior to nursing facility admission.
Level I Required Documentation
In the event the NCMUST system flags a screen for a manual review, the NC Medicaid PASRR nurse will request submission of patient information to complete the Level I manual review.
The following information will be required:
- Most recent history and physical (H & P).
- Comprehensive progress notes dated within the last 30 days.
- A comprehensive drug history including current or immediate past use of medications.
- A copy of the FL2 documenting diagnosis, dated within the last 30 days and signed by a physician (MD or DO).
- Psychiatric notes if available.
Level I screens do not apply to the following individuals:
- Individuals who have had a previous Level I screening and are re-admitted to a nursing facility after treatment in a hospital, unless there has been a significant change of condition in which SMI, I/DD or RC is present or suspected to be present. Such cases would be submitted to NC Medicaid via NCMUST following readmission.
- Individuals who have had a valid PASRR Level II evaluation and transfer from one facility to another. However, the tracking module located in NCMUST should be used to report the transfer of these individuals.
- Individuals admitted to swing beds, adult care home beds, rest home beds or other facility/bed types that do not participate in the NC Medicaid program, or are not considered Medicaid-certified nursing facilities.
Level I Outcomes
As a result of the manual review of the Level I screen, the following outcomes may occur:
Negative Finding: If after the manual review there is no indication of SMI, I/DD, RC and the individual is determined not to meet the target population, an "A" alpha character at the end of the PASRR review number will be assigned.
Positive Finding: If after the manual review, SMI, I/DD or RC is suspected, a referral for a Level II evaluation will occur. A submitted Level I screen suggests the individual may have SMI, I/DD or RC.
The following situations define temporary, time-limited nursing facility admissions for individuals with a SMI, I/DD and RC diagnosis meeting federal and State-specified criteria. These admissions will be permitted following submission of a Level I screen and required medical documentation. A subsequent NC Medicaid authorization number is issued with an end date for the time-limited stay. If the individual's stay is expected to exceed the allotted time frame, the receiving facility must update the Level I screen prior to expiration of that time period. This may result in a referral for a Level II evaluation.
Convalescent Care Admissions (30-calendar-day) are federally allowed without a Level II screen, if all the following conditions are met:
- Admission to a skilled nursing facility (SNF) occurs directly from a general hospital after receiving acute inpatient medical care; and
- SNF services are required for the hospitalized condition; and
- the hospital attending physician has certified that SNF care is unlikely to exceed 30 calendar days.
The physician certification must be provided to NC Medicaid at the time of the screen. If at any time it appears that the individual's stay may exceed 30 days, and no later than the 25th calendar day, the receiving facility must submit an updated Level I screen to NC Medicaid to determine whether further evaluation under the Level II process may be necessary.
Provisional Admission allows for temporary (seven-day) admission of persons whose delirium precluded the ability to make an accurate diagnosis. Facilities with admissions approved under this category must follow Level I screening procedures for an update, if the delirium clears, or no later than the fifth calendar day following admission.
Emergency Admission applies to nursing facility applicants who have evidence of SMI, I/DD or RC and require temporary nursing facility admission of no greater than seven calendar days in an emergency protective services situation. If at any time it appears that the individual's stay may exceed seven days, and no later than the fifth calendar day, the receiving facility must submit an updated Level I screen to NC Medicaid to determine whether further evaluation under the Level II process may be necessary.
This standard applies if:
- based on the SMI, I/DD or RC individual's physical and/or environmental condition, there is a sudden and unexpected need for immediate SNF placement; and
- the above need requires temporary placement until alternative services and or placement can be secured and no other placement options are available.
Respite allows temporary (seven-day) care for an individual with SMI, I/DD or RC to allow respite for the caretaker to whom the individual will return following the temporary stay. If at any time it appears that the individual's stay may exceed seven days, no later than the fifth calendar day, the receiving facility must submit an updated Level I screen to NC Medicaid to determine whether further evaluation under the Level II process may be necessary.
Time-Limited Request Process
The referral source submits the North Carolina Level I Screening Form via NCMUST.
- If the individual has evidence of SMI, I/DD or RC and a 30-day or a seven-day time limited PASRR is requested, a time-limited PASRR authorization is assigned by NC Medicaid with an alpha character ending of D or E.
- If the individual is a Medicaid recipient, the screener contacts NCTracks and proceeds with the Medicaid nursing facility prior approval process.
- If the resident is to remain beyond the authorized time frame, the receiving facility contacts NC Medicaid prior to the end date to update the Level I information
- Contact within:
- five days for a seven-day authorization.
- 25 days for a 30-day authorization.
- 50 days for a 60-day authorization.
- NC Medicaid refers the individual for a Level II evaluation.
- If approved through the Level II process, the facility contacts NCTracks and submits a new PA request.
A Level II evaluation is triggered when a Level I screening indicates a suspicion, or produces evidence, of serious mental illness (SMI), intellectual or developmental disabilities (I/DD) or a related condition (RC) as defined by State and federal guidelines. The Level II evaluation has three main aims:
- To confirm whether the applicant has SMI, I/DD.
- To assess the applicant’s need for nursing facility service.
- To assess whether the applicant requires specialized services or specialized rehabilitative services.
If a patient is determined to meet the federal criteria for Level II evaluation, a NC Medicaid PASRR nurse will initiate a Level II referral and notify the screener via North Carolina Medicaid Uniform Screening Tool (NCMUST). The Level II evaluation must be completed within seven business days of the referral and must be prior to the individual's admission to a Medicaid-certified nursing facility, except in those situations where a provisional admission is applicable. NCMUST will provide the facility with a NC Medicaid PASRR authorization for the screened individual regardless of payor source.
Level II Process
- The screener is notified of a Level II referral, at which time the Level II evaluator will confirm patient location and schedule the Level II evaluation within 24 hours of referral receipt.
- An in-depth evaluation is performed by a qualified mental health professional.
- A summary of findings documenting recommended placement and specialized services needs is completed.
- A final determination is made by DMH/DD/SAS and a PASRR authorization is assigned.
- A final determination letter is mailed to the resident/responsible party informing them of the final decision and/or their appeal rights.
- If the individual is a Medicaid recipient, the screener contacts Medicaid's NCTracks and proceeds with the Medicaid nursing facility prior approval process.
- The receiving nursing facility enters tracking information into NCMUST.
- The North Carolina Level I Screening Form and all associated supporting screening information is available on the NCMUST application to the nursing facility.
All Level II evaluation outcomes are made available to the screeners via NCMUST. The applicant/resident and/or legal guardian will also receive written notification accompanied by notification of appeal rights through the fair hearing process.
The Division of Mental Health, Developmental Disabilities and Substance Abuse Services (DMH/DD/SAS) is the agency that will make final determinations regarding appropriateness of placement and need for specialized services. In cases where specialized services are determined necessary, the DMH/DD/SAS will arrange for provision of those services.
A “significant change in condition” is defined as a major decline or improvement in a resident’s status that
- Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered “self- limiting.” (NOTE: Self-limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition.)
- Impacts more than one area of the persons health status.
- Requires interdisciplinary review and/or revision of the care plan.
A significant change in condition applies to individuals previously identified by PASRR and individuals who may not have been identified as having a SMI, I/DD or RC condition at the time of admission.
In instances where the individual was previously identified by PASRR to have serious mental illness, intellectual disability or a related condition, the nursing facility staff completes the North Carolina Level I Screening Form and submits it via the NCMUST. The following conditions may be noted as the reason for referral (note: this is not an exhaustive list):
- An individual who demonstrates increased behavioral, psychiatric or mood-related symptoms.
- An individual with behavioral, psychiatric or mood-related symptoms that have not responded to ongoing treatment.
- An individual who experiences an improved medical condition—such that the individual’s plan of care or placement recommendations may require modification.
- An individual whose significant change is physical, but with behavioral, psychiatric or mood-related symptoms, or cognitive abilities that may influence adjustment to an altered pattern of daily living.
- An individual whose condition or treatment is, or will be, significantly different than described in the individual’s most recent PASRR Level II evaluation and determination.
In instances where the individual had not previously been found by PASRR to have a serious mental illness, intellectual disability/developmental disability or a related condition, the nursing facility staff completes the North Carolina Level I Screening Form and submits it via NCMUST. The following conditions may be noted as the reason for referral (note: this is not an exhaustive list):
- An individual who exhibits behavioral, psychiatric or mood-related symptoms suggesting the presence of a diagnosis of serious mental illness as defined under 42 CFR §483.102 (where dementia is not the primary diagnosis).
- An individual whose intellectual disability as defined under 42 CFR §483.102, or whose related condition as defined under 42 CFR §435.1010, was not previously identified and evaluated through PASRR.
- An individual who has been transferred, admitted or re-admitted to a nursing facility following an inpatient psychiatric stay or equally intensive treatment.
The tracking module located in NCMUST is used to monitor location and due date information to assure timely PASRR evaluations for persons with serious mental illness (SMI), intellectual or developmental disabilities (I/DD) or a related condition (RC). Information must be entered in the tracking module for individuals who have received a Level II authorization if any of the following apply:
- First time admission to a Medicaid-certified nursing facility.
- Transfer to another Medicaid-certified facility.
- Discharge from the nursing facility system.
A medical form that lists the physician's recommended level of care as well as other patient health information including medical diagnoses, care needs and medications.
H&P – History and Physical
A medical document that provides information about a patient's history and exam findings.
Intellectual or developmental disability (I/DD) for PASRR Purposes
A disability characterized by significant limitations in both intellectual functioning and in adaptive behavior and originates before the age of 22.
Level I Screen
A screening required for all individuals applying to reside in a Medicaid-certified nursing facility. A screening designed to ask specific diagnostic and functional questions about a person in order to identify those individuals with MI, I/DD or RC.
Level II Evaluation
An in-depth evaluation by a qualified mental health professional to assess for nursing facility placement and potential specialized care needs of the individual.
NCMUST - North Carolina Medicaid Uniform Screening Tool
The self-service, internet-based application used to manage the NC Pre-admission Screening and Resident Review (PASRR) Program.
Serious Mental Illness (SMI) for PASRR Purposes
- A diagnosis or suspicion of a major mental illness such as schizophrenia, bipolar disorder, major depression or an anxiety disorder such as OCD.
- An absence of dementia. If dementia is also present (co-morbid with) mental illness (MI), it cannot be the primary diagnosis. The individual’s MI must be more serious than their dementia.
- A well-defined duration. To be relevant, intensive psychiatric treatment for MI must have taken place within the last two years.
- A particular level of disability. The individual’s MI must have resulted in functional limitations in major life activities within the past three to six months. Crucially, the individual need not have received treatment. It is the severity and recency of impairment that matters, not whether the individual was hospitalized or even saw a mental health professional.
Pre-Admission Screening and Resident Review (PASRR)
A federally required screening of any individual who applies to, or resides in, a Medicaid-certified nursing facility, regardless of the source of payment.
Related Condition for PASRR Purposes
A related condition, which is defined by 42 CFR 435.1010 as a disability that:
- Is attributable to:
- Cerebral palsy or epilepsy; or
- Any other condition, other than mental illness, found to be closely related to intellectual disability because it impairs intellectual functioning or would require services normally delivered to an individual with impaired intellectual functioning;
- Manifests before the age of 22;
- Is likely to continue indefinitely; and
- Results in substantial functional limitations in three or more of the following life activities:
- Understanding and use of language
- Capacity for independent living
A screener is the individual who initiates the PASRR Level I screening in NCMUST