PAE rules can be vexing
The PAE is valid for 90 calendar days, unless an earlier expiration date is assigned by the Bureau of TennCare. A valid approved PAE that has not been used within 90 days must be updated before it can be used. The eexpiration Date is a date assigned by the Bureau of TennCare at the time of approval of a PAE after which Medicaid reimbursement will not be made unless a new PAE is submitted and approved, or 365 days after the PAE Approval Date when the PAE has not been used. A PAE is “used” when the individual has begun receiving long-term care services based on the level of care approved in the PAE. A PAE is “expired” when the individual has not begun receiving long-term care services on or before the 365th day. The first claim for reimbursement may be submitted after the 365th day, so long as the first date of service is on or before the 365th day.
In order for an individual to be eligible for CHOICES 1 benefits, he must have completed the Pre-admission Screening and Resident Review (PASRR), have an approved, unexpired Pre-admission Evaluation (PAE) for NF LOC, be approved for TennCare reimbursement of NF services, and be admitted to a NF. The effective date of eligibility may be retroactive to the date of admission, or the date of the application, whichever is later.
PAE certification is a process by which a physician who is licensed as a doctor of medicine or doctor of osteopathy signs and dates a PAE signifying that: (1) the person requires the requested level of institutional care or reimbursement (Level 1 NF, Level 2 NF, Enhanced Respiratory Care, or ICF/MR) or, in the case of a section 1915(c) HCBS waiver program, requires HCBS as an alternative to the applicable level of institutional care for which the person would qualify; and (2) the requested long-term care services are medically necessary for the individual. Physician certification is not required for CHOICES HCBS.
To summarize key information:
· PAEs are either given an end date or are “open ended”
· Once approved, you have 365 days to use or bill on a PAE or it will expire
· For NF PAEs when you are ready to use the PAE, you must enter a Medicaid Only Payor Date (MOPD) to the PAE
· When you are ready to bill on the approved PAE if it has been 90 days or more since the approval date you must update or “recertify” the PAE.
· Once you have used the PAE the PAE is effective until either the end date or the Person’s LOC changes.