PASRR General Overview
What is PASRR’s background and purpose?
The Nursing Home Reform Act was passed as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA-87), and amended by Public Law 100-203 and 101-508, creating the Preadmission Screening and Resident Review (PASRR) process.
The purpose of PASRR is to ensure that individuals being considered for admission to a Medicaid certified nursing facility (NF) are evaluated for evidence of possible PASRR conditions, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or a related condition (RC). PASRR grants special protections to individuals with SMI, ID/DD, or RC to ensure they receive services in the most integrated setting. PASRR ensures that individuals being admitted to, or residing in a NF, receive services or supports that address their PASRR condition, including services linked to that condition, i.e., specialized services.
The PASRR process consists of a Level 1 Screening, a Level 2 Evaluation (depending on the outcome of the Level 1 Screening), and a Determination. A Determination is defined as a decision made by the mental illness (MI) or ID state authority, delivered by a provider, that include placement and treatment recommendations that are most appropriate for an individual.
Who are the state MI and ID authorities?
The Department of Health Care Services (DHCS) is the state’s MI authority responsible for making a determination as to whether an individual identified with an SMI requires the level of care provided by a NF and whether specialized services are needed. This determination is made based on the findings of the Level 2 Evaluation.
The Department of Developmental Services (DDS) is the state ID authority responsible for making a determination as to whether an individual identified with an ID/DD or RC requires the level of care provided by a NF and whether specialized services are needed. This determination is made based on the findings of the Level 2 Evaluation.
PASRR Federal Authority
DHCS’ Corrective Action Plan (CAP)
DHCS has an active CAP with CMS, because California has been out of compliance with ensuring a PASRR is completed prior to individuals discharging from a hospital to a NF, and prior to individuals being directly admitted from the community to a NF. The CAP requires California to be preadmission compliant by July 1, 2023.
In an effort to become compliant, DHCS upgraded its PASRR Online System to allow hospitals and NFs to submit Level 1 Screenings electronically. The new system also supports the exchange of electronic PASRR documents and case tracking. This allows providers, Level 2 evaluators, and state agencies to submit, transfer, and obtain required documentation associated with an individual’s PASRR.
DHCS initiated a pilot from December 1, 2022, to January 31, 2023. During the pilot, six hospitals used the upgraded PASRR Online System to complete the PASRR process electronically, prior to an individual discharging to a NF.
Remaining hospitals were enrolled in the upgraded PASRR Online System in April 2023. The hospital onboarding schedule, training, and go live dates have been posted and can be found at:
PASRR Onboarding Schedule
After a hospital completes enrollment and training, it is required to submit Level 1 Screenings electronically using the PASRR Online System, and if needed, arrange for Level 2 Evaluations to be performed by a state approved contractor to help ensure individuals discharging from the hospital to a NF to receive services in the most integrated setting.
NFs are also required to submit Level 1 Screenings electronically using the PASRR Online System, and if needed, arrange for Level 2 Evaluations to be performed by a state approved contractor to help ensure individuals seeking NF admissions receive services in the most integrated setting.
What is the PASRR process?
PASRR consists of a Level 1 Screening, a Level 2 Evaluation (if needed), and a Determination.
The PASRR process is divided into two components, the Preadmission Screening (PAS) and the Resident Review (RR). The PAS process is completed by the hospital prior to an individual discharging to a NF. A NF can also complete the PAS process, but only when the individual is being admitted directly from the community. The RR process is completed for current NF residents, readmissions, or inter-facility transfers when there is a significant change in the individual’s physical or mental condition. In the case of an RR, the NF initiates the process by submitting a Level I Screening as an RR in the PASRR system.
A Level 1 Screening is used to identify if an individual has, or is suspected of having, a PASRR condition, i.e., SMI, ID/DD, or RC. If the Level 1 Screening in either scenario is positive for an individual as having, or is suspected of having a PASRR condition, then a Level 2 Evaluation will be performed, and a Determination made.
Note: A readmission is a member who is already admitted to the NF; leaves to the hospital to receive care with return anticipated; and returns to the NF. An inter-facility transfer is a member who transfers from one NF to another, with or without an intervening hospital stay. The transferring NF is responsible for ensuring copies of the member’s most recent electronic PASRR accompany the transferring member.
Which health care facilities are subject to PASRR?
Hospitals discharging to a SNF are subject to the PASRR process. This includes California’s:
- Freestanding Children’s Hospitals
- Veteran Affairs Hospitals; and
- Freestanding acute psychiatric hospitals
All Medicaid certified NFs are subject to the PASRR process. This includes California’s:
- Intermediate care facilities, also known as NF-As and skilled nursing facilities also known as NF-Bs, both distinct part and freestanding, certified by Medicaid to provide nursing facility level of care services;
- Institution for Mental Disease (IMD) that are designated as Special Treatment Program/Skilled Nursing Facilities; and
- Subacute care facilities unless the facility has a Medicare-approved swing bed arrangement.
Note: Most PASRR Level 1 Screenings on subacute level of care patients are going to be negative, because of overriding medical conditions.
Is PASRR required only for NFs certified by Medicaid, or is it required for Medicare certified nursing facilities as well?
A PASRR is required only when an individual is being discharged to a Medicaid certified NF. A PASRR is not required for discharge to Medicare certified NFs.
Who is subject to PASRR?
Is PASRR required for anyone being admitted to a NF?
Yes, a Level 1 Screening, a Level 2 Evaluation (if needed), and Determination must be completed for any individual discharging from a hospital to a NF, or for any individual being directly admitted from the community to a NF, regardless of the individual’s age or payor source.
If the individual's primary insurance is Medicare with Medi-Cal as secondary, is a PASRR still required?
Yes, a PASRR is required for any individual discharging from a hospital to a NF, or for any individual being directly admitted from the community to a NF, regardless of the individual’s age or payor source.
What if the member is pending Medicaid approval? Is a PASRR required?
Yes, a PASRR is required for any individual discharging from a hospital to a NF, or for any individual being directly admitted from the community to a NF, regardless of the individual’s age or payor source.
Does PASRR apply to Health Maintenance Organization (HMO) members?
Yes, a PASRR is required for any individual who may be discharging from a hospital to a NF, or for any individual being directly admitted from the community to a NF, regardless of the individual’s age or type of insurance coverage they have (payor source).
How does the CAP impact providers?
How was a PASRR completed prior to the CAP, and what has changed with the new PASRR process?
Historically, California has not been preadmission compliant. This means NFs received reimbursement for individuals who were discharged from hospitals to NFs, and for individuals directly admitted from the community to NFs, without completed PASRRs.
The new process requires that hospitals now complete Level 1 Screenings and ensure that the PASRR process is complete prior to an individual discharging from a hospital to an NF. If an individual is sent to a NF directly from the community, the NF is responsible for completing the Level 1 Screening prior to admission. It is important to note that NFs will no longer receive reimbursement for any day an individual is in the NF without a completed PASRR.
Can NFs continue to receive reimbursement for individuals that are admitted without a completed PASRR?
No. NFs will no longer receive reimbursement for any day an individual is in the NF without a completed PASRR.
Is there a penalty for admitting an individual to a NF without a PASRR Determination?
Consequences for admitting an individual to a NF prior to the PASRR process being completed include the NF forfeiting Medi-Cal reimbursement, the NF’s records may be audited to ensure prior FFP was appropriately claimed, and sanctions may be imposed if the NF is noncompliant with federal PASRR regulations.
Do we now have to wait for the PASRR process to be complete prior to discharging a patient from the hospital to a NF?
Yes. A PASRR must be completed prior to a hospital discharging an individual to a NF. A PASRR must also be completed prior to an individual being admitted to the NF directly from the community. Please note, the PASRR process has been designed to minimize disruption in the transition of an individual to a NF.
Will hospitals receive administrative days for Medi-Cal member days that accumulate while a PASRR is being completed?
Hospitals will receive Medi-Cal Acute Administrative Days (AAD) while waiting for NF placement. This reimbursement is only for justifiable administrative days while waiting for PASRR completion, assuming the delay is not on the hospital’s part and the reasons for the delay are well documented.
This applies to Medi-Cal members only and would follow current Medi-Cal AAD policy.
Will other insurance providers continue to pay us while we wait for the PASRR process to be completed?
DHCS does not have authority over payment by other insurance providers. For payment and contractual agreements with other insurance providers, please contact the insurance provider directly.
A hospital should start the PASRR process with a Level 1 Screening upon admission of the individual, or as soon as there is an indication the individual may discharge to a NF. This will allow for the completion of a Level 2 Evaluation (if needed) and Determination prior to discharge.
Will health plans deny pay for the delay in the Level 2 Evaluation, since we were told the Level 2 Evaluation can take up to 7 business days?
DHCS does not have authority over payment by other insurance providers. For payment and contractual agreements with health plans, please contact the health plan directly.
To minimize potential delays and/or denial of payment, we recommend that hospitals start the PASRR process with a Level 1 Screening upon admission, or as soon as there is an indication the individual may be discharged to a NF. This will support timely completion of a Level 2 Evaluation (if needed) and Determination prior to discharge.
What is the difference between a <30-day length of stay (LOS) and a >30-day LOS?
The purpose of PASRR is to ensure that anyone with a qualifying condition will be evaluated to determine if they need services specific to those conditions that are “over and above” what the NF would be expected to provide. A 30-day or less LOS indicates the individual will not be in the NF long enough to benefit from these services.
Are NF’s on board with holding a bed while waiting for the PASRR or Reconsideration process to be completed?
A request for a bed hold will have to be negotiated between the hospital and NF directly. Initiating the PASRR process will not guarantee a bed will be held. To ensure timely completion of the PASRR process, we recommend that hospitals submit the Level 1 Screening upon admission.
How will CalAIM affect the hospital billing process?
Under CalAIM, for members enrolled in a Medi-Cal Managed Care Health Plan (MCP), hospitals are required to submit the completed PASRR documents to the MCP when submitting a NF referral for prior authorization. Hospitals cannot discharge the member until the MCP approves the prior authorization.
Does the social worker still do the 10-facility Call List notes while waiting? Even if we have an accepting facility?
There is no change to Medi-Cal’s 10-facility Call List process. Once there is confirmation from an accepting NF, daily calls are no longer necessary. The PASRR documents can be sent to the NF using the electronic File Exchange within the PASRR Online System.
Does the PASRR process affect the NF seven-day bed hold policy?
No. A PASRR does not affect the NF seven-day bed hold policy. If a PASRR was completed and there is no significant change in the resident’s physical or mental condition, a new PASRR is not needed. This is also applicable if in-hospital attention takes several weeks (exceeding the standard bed hold timeframe, and a new treatment authorization request is required by the NF upon a resident’s return).
Does DHCS have requirements for medical record documentation and integration into the electronic health record (EHR)? Has any communication been directed to health information technology (HIT) departments? Our staff are encountering questions as they pursue implementation.
DHCS has no requirements for medical record documentation and/or integration into EHR at this time. Hospitals should work directly with the DHCS contractor (Kepro) and DDS Regional Centers to provide Level 2 evaluators access to their EHR (or similar system) so evaluators may complete Level 2 Evaluations.
Please direct EHR related inquiries to Kepro or DDS as follows:
Kepro
DDS
- Phone: (916) 653-0791
- Fax: (916) 654-3256
How can I receive PASRR training and onboarding?
What are DHCS' PASRR training requirements for hospitals and NFs?
NFs are encouraged to participate in the live trainings sessions that are currently being offered twice a month. For specific details about the live training sessions for NFs please check the
PASRR Events Schedule. Additional
training materials for NFs is also available.
What training materials are available, and where are they located?
DHCS PASRR training materials include:
Recorded Trainings:
- Recorded PASRR Overview Training (required)
- Recorded PASRR Online System Navigation Training (optional)
- The PASRR Level 1 Screening Demonstration Training (optional)
- Microsoft Azure Organization Tutorial (optional)
Other training resources:
- Microsoft Azure Registration Manual
- PASRR Online System User Guide updated 1/2023
- PASRR Level 1 Assessment (Screening) Guide
How do I certify my hospital has completed the required PASRR training?
Are staff who currently use the PASRR Online System required to take training?
If your staff is already active in the PASRR Online System and submitting PASRRs, they do not need to complete the required training.
How do I enroll in the hospital trainings?
DHCS now offers PASRR training virtually. All training materials are posted to DHCS’
PASRR Training pages.
Where can I find more information and training opportunities?
Please routinely visit DHCS’
PASRR Training pages for updated PASRR information and training.
Who do we reach out to if we want training for our facility only?
If the member is admitted prior to the hospital specific “go live” date, do I still need to do the PASRR?
A PASRR would not be needed in this instance.
