Minimum data set (MDS) Form Step 1 of 10 10% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Date of RN Assessment* MM slash DD slash YYYY Name* First Last Error Message Facility InformationHome Care Agency NPI* Home Care Agency* Error Message Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* RN signature*Authorization is not a guarantee of payment Section B: Cognitive PatternsMemory*Short Term Memory appears OK- seems to recall after 5 minutes Memory OK Memory problems Cognitive Skills for Daily Decision making*How well the client made decisions about organizing the day e.g. when to get up or have meals, which clothes to wear Independent - decisions consistently reasonable Modified Independence - Some difficulty in new situations Moderately Impaired - Decisions poor, cues/supervision Severely Impaired - Never/rarely makes decisions Indicators of Delirium*Sudden or new onset/change in mental function (including ability to pay attention, awareness of surroundings, coherentness) NO YES In the last 90 days, client has become disoriented or agitated such that his/her safety is endangered or client requires protection by others* NO YES Total Cognitive*(calculated by adding above scores) Section E: Mood and Behavior Patterns Indicators of depression, anxiety, sad moodA feeling of sadness or being depressed, that life not worth living, that nothing matters, that he/she is of no use to anyone or would rather be dead* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Persistent anger with self or others* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Expression of what seem to be unrealistic fears* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Repetitive health Complaints* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Repetitive, anxious complaints/concerns* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Sad, Pained, worried facial expressions* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Recurrent Crying/Tearfulness* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Withdrawal from activities of interest* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Reduced Social interaction* Not exhibited in the last 30 days Exhibited up to 5 times each week Exhibited daily Total Mood*(calculated by adding above scores) Behavior PatternsBehavioral symptoms exhibited in the past seven days Wandering*(moved with no rational purpose) Did not occur in past seven days Occurred, easily altered Occurred, not easily altered Verbally Abusive Behavior* Did not occur in past seven days Occurred, easily altered Occurred, not easily altered Physically abusive*(to self or others) Did not occur in past seven days Occurred, easily altered Occurred, not easily altered Socially Inappropriate/Disruptive behavior* Did not occur in past seven days Occurred, easily altered Occurred, not easily altered Aggressive Resistance of Care*(Threw med, pushed care giver, etc.) Did not occur in past seven days Occurred, easily altered Occurred, not easily altered Changes in behavior* NO YES Total Behavior*(calculated by adding above scores) Section H: Physical Functioning - activities of daily living(consider all instances over past seven days)Mobility in Bed*moving to and from lying position, turning and positioning body in bed Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Transfer to and between surfaces*Bed, chair, standing position (excluding bathroom transfers) Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Locomotion in home*If in wheelchair, self-sufficiency one in chair Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Dressing*Includes laying out clothes, retrieving from closet, putting on and taking off Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Eating*Includes taking in food by any method including tube-feeding Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Toileting*Includes using toilet, commode, bedpan, urinal, catheter, transfers, cleaning self and managing clothing Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Personal Hygiene*Combing hair, brushing teeth, washing face and hands, shaving Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Bathing*Includes shower, sponge bath, tub bath Independent – No help or oversight Supervision- oversight or cueing provided 3 or more times, possible physical assistance less than 3 times Limited assistance- Client highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times Extensive Assistance- client participated, but weight bearing support or full assistance given three or more times Total dependence- Full performance of activity by another over entire seven days Activity did not occur over entire seven days regardless of ability Indoor Locomotion* No assistive device Cane Walker/Crutch Scooter Wheelchair Activity does not occur over entire seven days regardless of ability Outdoor Locomotion* No assistive device Cane Walker/Crutch Scooter Wheelchair Activity does not occur over entire seven days regardless of ability Total ADL*(calculated by adding above scores) Instrumental Activities of Daily LivingCode for functioning in everyday activities in the homeMeal Preparation* Independent Help some of the time Needs help all of the time Always performed by others Activity did not occur Ordinary Housework* Independent Help some of the time Needs help all of the time Always performed by others Activity did not occur Managing Financing* Independent Help some of the time Needs help all of the time Always performed by others Activity did not occur Managing Medication* Independent Help some of the time Needs help all of the time Always performed by others Activity did not occur Phone Use* Independent Help some of the time Needs help all of the time Always performed by others Activity did not occur Shopping* Independent Help some of the time Needs help all of the time Always performed by others Activity did not occur Transportation* Independent Help some of the time Needs help all of the time Always performed by others Activity did not occur Enhanced Reimbursement$1.00 per hour of combined personal car/home maker services. Services provided to a member assessed as being high acuity by the agency Registered nurse based on sections of the Minimum Data Set (MDS) for Home CareQualifications: A client is considered high acuity if they receive a following minimum score by an agency Registered Nurse in one area: a. “ on Section B items 1,2,3 OR b. “16” on Section E, Item 1, OR c. “8” on section E Items 2 and 3 OR d. “36” on Section H, items 1,2, and 3 Or, if they receive the following minimum scores in two or more areas a. “3” on Section B Items 1,2,3 b. “8” on Section E item 1 c. “4” on Section E items 2 and 3 d. “18” on Section H, Items 1,2, and 3 The agency must collect and submit this data to Neighborhood’s Utilization Department on all Integrity members in order to receive the enhancement for those with high acuity For all Integrity members that meet the minimum criteria described above, an authorization will be entered into the system upon receipt of the completed MDS form All MDS forms must be signed by an RN, dated, and totaled for each section Claims submitted for members meeting the acuity standard should be billed at the correct amount with the modifier “U9” Neighborhood’s UM staff will enter the necessary information from the MDS forms into the electronic member record system for those members meeting high acuity criteria. This will allow the enhanced payment to be paid only on the appropriate claims. Medical Management staff will review and monitor the MDS data and member assessments as necessary. Request Method* Standard Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited. Attach additional documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited Request)Signature Date CommentsAuthorization is not a guarantee of paymentCAPTCHA