"Nursing Facility Tracking Form" - Nevada

This "Nursing Facility Tracking Form" is a Nevada-specific form released by the Nevada Department of Health and Human Services on November 6, 2013.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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Download "Nursing Facility Tracking Form" - Nevada

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CONFIRMATION PAGE
Please Print - Thank you for your submission
DIVISION OF HEALTH CARE FINANCING AND POLICY – NEVADA MEDICAID
NURSING FACILITY TRACKING FORM
To be submitted within 72 hours of any occurrence listed below for Medicaid Eligible individuals only
This form is to be used only if Medicaid is the primary payment source for this nursing facility stay. Failure of the facility to submit
this tracking form within 72 hours of any occurrence listed below may result in payment delays or denials.
Please fax to Long Term Support Services Unit: 775-687-8724
Medicaid Billing #: _______________ Social Security #: _______________ Date of Birth: _____________________
Recipient’s Last Name: _________________________ First Name: _____________________ MI: ______________
Facility Name: _____________________________________________ Provider #: ____________________________
SECTION I
ADMISSION INFORMATION: Nursing Facility Admission Date: ______________________________________
Does this resident have a PASRR Level I Identification screening and PASRR Level II Evaluation (if applicable) completed
prior to this admission date? _____________________________________________________________________
If yes, Indicate completion date:
PASRR Level I: ____________
PASRR Level II: _______________________
If the PASRR is time limited, indicate the limitation date: _______________________________________________
Does this resident have a Level of Care (LOC) screening? _____ If yes, indicate completion date: _______________
If the LOC is time limited, indicate the limitation date: _________________________________________________
SECTION II
PAYMENT INFORMATION:
_____________________________
Date you are requesting Medicaid Payment to begin:
REASON FOR PAYMENT REQUEST: __________________________________________________________
Indicate the Service Level Category for this resident: __________________________________________________
SECTION III
DISCHARGE INFORMATION:
____________________________________________________
Discharge date:
REASON FOR DISCHARGE: __________________________________________________________________
Transfer (name of Facility): ______________________________________________________________
Hospice Enrollment (name of Hospice): _____________________________________________________
PASRR II Determination (resident discharged to): ______________________________________________
Form Completed By (Please Print): ____________________________________________ Date: ______________________
E-Mail Address: ________________________________________________________________________________________
Comments: ____________________________________________________________________________________________
_______________________________________________________________________________________________________
For Official Uses Only
PASRR: _______________________
LOC: ___________________
DATE COMPLETED: ______________________
11/6/2013
CONFIRMATION PAGE
Please Print - Thank you for your submission
DIVISION OF HEALTH CARE FINANCING AND POLICY – NEVADA MEDICAID
NURSING FACILITY TRACKING FORM
To be submitted within 72 hours of any occurrence listed below for Medicaid Eligible individuals only
This form is to be used only if Medicaid is the primary payment source for this nursing facility stay. Failure of the facility to submit
this tracking form within 72 hours of any occurrence listed below may result in payment delays or denials.
Please fax to Long Term Support Services Unit: 775-687-8724
Medicaid Billing #: _______________ Social Security #: _______________ Date of Birth: _____________________
Recipient’s Last Name: _________________________ First Name: _____________________ MI: ______________
Facility Name: _____________________________________________ Provider #: ____________________________
SECTION I
ADMISSION INFORMATION: Nursing Facility Admission Date: ______________________________________
Does this resident have a PASRR Level I Identification screening and PASRR Level II Evaluation (if applicable) completed
prior to this admission date? _____________________________________________________________________
If yes, Indicate completion date:
PASRR Level I: ____________
PASRR Level II: _______________________
If the PASRR is time limited, indicate the limitation date: _______________________________________________
Does this resident have a Level of Care (LOC) screening? _____ If yes, indicate completion date: _______________
If the LOC is time limited, indicate the limitation date: _________________________________________________
SECTION II
PAYMENT INFORMATION:
_____________________________
Date you are requesting Medicaid Payment to begin:
REASON FOR PAYMENT REQUEST: __________________________________________________________
Indicate the Service Level Category for this resident: __________________________________________________
SECTION III
DISCHARGE INFORMATION:
____________________________________________________
Discharge date:
REASON FOR DISCHARGE: __________________________________________________________________
Transfer (name of Facility): ______________________________________________________________
Hospice Enrollment (name of Hospice): _____________________________________________________
PASRR II Determination (resident discharged to): ______________________________________________
Form Completed By (Please Print): ____________________________________________ Date: ______________________
E-Mail Address: ________________________________________________________________________________________
Comments: ____________________________________________________________________________________________
_______________________________________________________________________________________________________
For Official Uses Only
PASRR: _______________________
LOC: ___________________
DATE COMPLETED: ______________________
11/6/2013
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