What is a PASRR Level 2 Evaluation, and when is it required?
PASRR consists of a Level 1 Screening, a Level 2 Evaluation (if needed), and a Determination.
If the Level 1 Screening is positive, a PASRR Level 2 Evaluation will be performed. A Level 2 Evaluation is a person-centered evaluation that is completed for anyone identified by the Level 1 Screening as having, or suspected of having, a PASRR condition, i.e., serious mental illness (SMI), intellectual disability (ID), developmental disability (DD), or related condition (RC).
The Level 2 Evaluation helps determine the most appropriate placement of an individual, considering the least restrictive setting, and whether specialized services are needed.
The Level 2 Evaluation has three main goals:
Confirm whether the individual has an SMI or ID/DD or RC;
Assess the individual’s need for Medicaid certified nursing facility (NF ) services; and
Assess whether the individual requires specialized services.
Note: Please see the PASRR General Overview FAQs for NF types that are subject to PASRR.
Who performs Level 2 Evaluations, and how are they scheduled?
Who performs an SMI Level 2 Evaluation, and how are they scheduled?
The Department of Health Care Services (DHCS) is responsible for arranging for SMI Level 2 Evaluations which, by law, must be performed by a third-party contractor independent of the state mental health authority. Currently, Acentra is DHCS' third-party contractor that performs SMI Level 2 Evaluations.
Prior to an SMI Level 2 Evaluation, an evaluator will contact your facility to obtain further details about the individual's mental and physical condition. If findings from the call support the need for a Level 2 Evaluation, an Acentra evaluator will arrange a day and time to perform the evaluations at your facility, or via telehealth, in an interview format.
Who performs an ID/DD or RC Level 2 Evaluation, and how are they scheduled?
The Department of Developmental Services’ (DDS) Regional Centers are responsible for providing ID/DD and RC Level 2 Evaluations.
Prior to an ID/DD or RC Level 2 Evaluation, DDS will contact your facility for additional details about the individual's condition. If findings from the call support the need for a Level 2 Evaluation, a DDS Regional Center evaluator will arrange a day and time to perform the Evaluation at your facility, or via telehealth, in an interview format.
Level 2 Evaluation Communications, Definitions & Questions
What is a Notice of Need letter?
A Notice of Need letter is issued by DHCS indicating that an individual needs an SMI Level 2 Evaluation. DDS Regional Centers do not issue Notice of Need letters for ID/DD or RC Level 2 Evaluations. Instead, they contact the facility directly to learn more and determine if a Level 2 Evaluation is needed.
What is a Notice of No Need letter?
A Notice of No Need letter is a document that indicates an individual does not need a Level 2 Evaluation. If applicable, a Notice of No Need letter will be issued by DHCS or one of DDS’ Regional Centers.
What is an SMI?
A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder. The disorder results in functional limitations in major life activities within the past 3 to 6 months that would be appropriate for the individual's developmental stage.
Functional limitations:
Interpersonal functioning. The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships and social isolation;
Concentration, persistence, and pace. The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these tasks; and
Adaptation to change. The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family, or social interaction, manifests agitation, exacerbated signs and symptoms associated with the illness, or withdrawal from the situation, or requires intervention by the mental health or judicial system.
Recent Treatment
Psychiatric treatment more intensive than outpatient care more than once in the past 2 years (e.g., partial hospitalization or inpatient hospitalization); or
Within the last 2 years, due to the mental disorder, experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials.
What is an ID/DD or RC?
Per Title 42, CFR, Section 482.102 (b)(3), an ID/DD or RC are severe and chronic disabilities that are attributable to a mental or physical impairment that begins before an individual reaches adulthood. These disabilities include intellectual disability, cerebral palsy, epilepsy, autism, and disabling conditions closely related to intellectual disability or requiring similar treatment.
Related conditions are not a form of ID, but often produce similar functional impairments and require similar treatment or services. Related conditions must emerge before the age of 18; they must be expected to continue indefinitely; and they must result in substantial functional imitations in three or more of the following major life activities:
Related conditions could include autism, cerebral palsy, Down syndrome, fetal alcohol syndrome, muscular dystrophy, seizure disorder, and traumatic brain injury. Please note this is not an exhaustive list.
How are needed services identified if the patient has a positive Level 1 Screening?
Needed services are identified based on information collected during a Level 2 Evaluation, which includes a review of the individual’s medical records, a person-centered interview or interview via Telehealth when necessary, and possibly interview of family members. These services are then reflected in the Determination letter.
Are Level 2 Evaluations performed in-person or via telehealth?
The Level 2 evaluator will work with the facility to choose whatever method is most efficient. However, a face-to-face interview is preferred.
Are there Level 2 Evaluations conducted after-hours, on weekends, and holidays?
The Contractor and DHCS conduct SMI Level 2 Evaluations and Determinations on weekends, after-hours, and on holidays, with the exception of major holidays. Regional Centers perform ID/DD or RC Level 2 Evaluations Monday to Friday 8 am to 5 pm only.
It seems 80% of our patients will trigger for depression and anxiety. Will there be exceptions, so not everyone requires a Level 2 Evaluation?
Depression and general anxiety alone, with no further evidence of a SMI will more than likely not trigger a Level 2 Evaluation. Generally, 90 percent of Level 1 Screenings do not result in a Level 2 Evaluation. The only exception would be if there was a categorical condition identified prior to a Level 2 Evaluation, which would allow the state to omit the full Level 2 Evaluation in certain circumstances that are time-limited or where the need for NF level of services is clear. Categorical determinations cover brief stays, delirium, severe physical illness, and terminal illness.
I received a No Need letter. Why is a Level 2 Evaluation not required for the individual?
The reasons a Level 2 Evaluation may not be required include:
There was no confirmed SMI, ID/DD, or RC; or
A 30-day Exempted Hospital Discharge (EHD) was certified by a physician.
Note: Please see the PASRR General Overview FAQs for hospital facility types that are subject to PASRR.
What is an EHD?
The only exemption under which a hospital is not required to fully complete the PASRR process is if the individual discharging to a NF qualifies for an EHD. Under this process, a Level 1 Screening is still required, but the EHD question can be marked “Yes” in the PASRR Online System.
All criteria listed below must apply to meet the 30-Day EHD exemption:
The individual is directly admitted to the NF from a hospital after receiving acute inpatient care at the hospital; and
The individual requires NF services for the same condition the individual was receiving care for in the hospital; and
The attending physician has certified prior to NF admission that the individual’s stay is likely to require less than 30 calendar days of NF services.
Note: if the individual’s stay exceeds the 30 calendar days, then the NF is required to submit a RR Level 1 Screening by the 40th calendar after admission.
How should I prepare for a Level 2 Evaluation?
What can the facility do to prepare for the Level 2 Evaluation?
A facility should:
Provide a private room for the individual and Level 2 evaluator.
Notify the Level 2 evaluator if interpreter services are needed for language or hearing.
Have the individual’s medical records available.
Notify the individual’s family members or conservator if consent was provided for them to participate in the Level 2 Evaluation.
If the evaluation is being performed via a telehealth session, please ensure that a clinical staff member is physically present with the individual during the evaluation.
Who will DHCS’ contractor (Acentra) contact?
DHCS’ contractor will contact the person who submitted the Level 1 Screening via the phone number provided. If you want another person to be contacted to assist in scheduling the SMI Level 2 Evaluation, the facility can communicate this directly to Acentra at:
Who will DDS Regional Centers contact?
DDS Regional Centers will contact the staff member who submitted the Level 1 Screening via the phone number provided. If you would like another staff member to be contacted to assist in scheduling the ID/DD or RC Level 2 Evaluation, the facility can communicate this directly to DDS at:
Phone: (916) 653-0791
Fax: (916) 654-3256
Can a facility designate whom to contact after-hours?
For SMI Level 2 Evaluations, the facility can provide an after-hours point of contact directly to Acentra at:
DDS Regional Centers are only available Monday to Friday from 8 am to 5 pm. As a result, no after-hours contacts can be designated for DDS.
What happens after a positive Level 1 Screening, i.e., does a DHCS contractor or DDS Regional Center representative contact me?
Yes. A representative from DHCS’ contractor or DDS Regional Centers will contact you to ask additional questions to confirm the individual has not been discharged and is capable of participating in the Level 2 Evaluation. A representative may also ask clarifying questions that have arisen from information provided on the Level 1 Screening, and/or they may need to confirm the intensity of the individual’s symptoms. This information is then shared with a Level 2 evaluator for further action, including any follow-up calls that are needed.
During the initial call, who will the DHCS contractor or DDS Regional Center representative want to speak with from my facility?
The representative from DHCS’ contractor or DDS Regional Centers will ask to speak to the staff person who completed the Level 1 Screening. The representative may also want to speak with the charge nurse or nursing supervisor assigned to the station caring for the individual. It is possible they may also ask to speak with a social services director or other key supervisory staff, or the individual, to ensure the necessary information is collected during the call. The representative may also need access to the individual’s medical records.
What additional questions will a Level 2 evaluator ask during their follow-up call?
Level 2 evaluators will ask additional questions about the individual’s mental and physical well-being, upcoming appointments, and current room/bed number assignment. In some instances, additional detailed questions may be asked about prescribed medications, diagnoses, and activity level. All of this information is utilized to confirm if a Level 2 Evaluation is necessary.
Who should participate in the Level 2 Evaluation?
The Level 2 evaluator and the individual. Family members and conservator (if applicable) can also participate if requested by the individual, and at least one facility staff person familiar with the individual should be accessible if the evaluator needs their input as part of the Level 2 Evaluation.
Are facilities directly informed about the results of an SMI Level 2 Evaluation?
Once the Level 2 Evaluation is complete, DHCS will generate a Determination letter within 24 hours. The Determination letter can be accessed by the facility in the PASRR Online System. However, facilities will not receive a notification when the final Determination letter is generated. As such, we recommend that facility staff continue to follow up on the status of the Determination letter in the PASRR Online System. For more information regarding Determinations, please refer to the PASRR Determination and TAR FAQs.
Are facilities directly informed about the results of an ID/DD or RC Level 2 Evaluation?
Once the Level 2 Evaluation is complete, the DDS Regional Center will send a copy of the Level 2 Evaluation directly to the facility.
What is the backup process to DHCS’ contractor if they don’t respond timely?
The hospital or NF can reach out directly to Acentra after submitting a positive Level 1 Screening.
Acentra can be reached as follows:
What is the backup process to DDS Regional Centers should they not respond timely?
The hospital or NF can reach out directly to DDS if they have not received a call within seven to nine business days after submitting a positive Level 1 Screening.
DDS can be reached as follows:
Phone: (916) 653-0791
Fax: (916) 654-3256
Does DHCS’ contractor and DDS have established hotlines just for PASRR questions?
There are no established hotlines just for PASRR. However, DHCS’ contractor and DDS respond quickly to inquiries regarding the PASRR program.
Does the suspected SMI need to be diagnosed by a psychiatrist at the facility?
No. The suspected SMI does not have to be diagnosed by a psychiatrist at the facility.
Should Level 2 evaluators have access to any health information exchange?
Yes. Level 2 evaluators will need access to an individual’s medical records when conducting the Level 2 Evaluation. DHCS recommends that facilities grant Level 2 evaluators access to their medical records systems or make the medical records available for the evaluator’s review for the scheduled Level 2 Evaluation to help expedite the process.
Do I have to keep patients in the hospital until the Level 2 Evaluation is complete?
Yes. Completion of the PASRR process is required prior to discharging an individual to a NF, including the Level 2 Evaluation (if needed) and Determination. Note: a Level 2 Evaluation will not be required in all cases.
How long does it take to determine if a Level 2 Evaluation is needed when there is a positive response to one of the screening questions?
Level 2 evaluators will contact the hospital within 24 hours of receiving a positive SMI Level 1 Screening to determine if a Level 2 Evaluation is needed. DDS Regional Centers may determine whether a Level 2 Evaluation is needed within 24 to 72 hours of a positive Level 1 Screening and have seven to nine business days to complete an ID/DD or RC Level 2 Evaluation and Determination (PASRR Summary Report).
How long does it take to schedule and complete the Level 2 Evaluation and receive a Determination letter?
After the Level 1 Screening indicates the individual is positive for SMI, it is electronically sent to DHCS’ contractor, for review and processing. The contractor is required to contact the hospital and complete a SMI Level 2 Evaluation, if needed, within 72 hours. Once the Level 2 Evaluation is complete, it is electronically sent to DHCS and reviewed by a Consulting Psychologist. Once this review is complete, the Determination letter will be available within 24 hours in the PASRR Online System.
DDS Regional Centers have seven to nine business days to schedule and complete an ID/DD or RC Level 2 Evaluation and Determination (PASRR Summary Report).
How long does a Level 2 Evaluation take to complete?
A Level 2 Evaluation between the evaluator and the individual may take up to an hour. However, this can vary depending on availability of:
Information and detail available in the charts/records;
A private place to conduct the Level 2 Evaluation;
The individual being interviewed; and
The individual's level of cooperation and functioning among other unforeseen factors.
What if an individual has a dual diagnosis of SMI and ID/DD or RC?
DHCS oversees the PASRR process for individuals identified with SMI. DDS oversees the PASRR process for individuals identified with ID/DD or RC.
Once the Level 1 Screening is submitted using the PASRR Online System, and it is positive for both SMI and ID/DD or RC, it will automatically be referred to both the DHCS’ contractor and DDS Regional Centers for further evaluation. Both entities will contact your facility to schedule a Level 2 Evaluation if needed.
What if the NF cannot manage the patient's needs related to the SMI or ID/DD or RC condition, and as a result, the NF will not accept the patient?
A NF’s reluctance to accept someone with a SMI, ID/DD or RC condition is often due to concerns regarding their ability to provide adequate services and supports to meet the needs of the individual. The hospital should continue to work with NFs in their network to place the individual in the NF that can best manage the patient’s needs.
What happens if the Level 2 Evaluation is not completed because the patient will not engage?
If the Level 2 Evaluation cannot be completed because the individual will not engage, the case is closed. DHCS and DDS Level 2 evaluators will make notes in the individual’s file and will close the PASRR as a Level 2 Attempt. The NF should attempt another Level 1 Screening to initiate a RR, as needed.
Is there a list of statewide Medicaid certified NFs?
All Medicaid-certified NFs can be found on the California Department of Public Health website at: Licensed and Certified Healthcare Facility Listing.
Will DDS provide responses to a facility electronically?
Please contact DDS directly regarding of the electronic delivery of PASRR documents.
DDS can be reached by:
Phone: (916) 653-0791
Fax: (916) 654-3256
If a patient is already a DDS Regional Center participant, is a Level 2 Evaluation still necessary?
The Regional Center would determine if a Level 2 Evaluation is needed. This process may be expedited because the individual’s information has already circulated with the Regional Centers.
If Section 2 and Section 3 on the Level I Screening are both YES, are two Level 2 Evaluations are needed, i.e., one from the DDS Regional Center and one from the DHCS’ contractor?
Yes. Positive screenings for both SMI and ID/DD or RC would be referred to DHCS’ contractor and DDS Regional Centers for further review and possible Level 2 Evaluations.
