MassHealth/Permedion HMS Government Services 
Telephone: 1-877-735-7416 

Fax: 1-877-735-7415 

Acute 

Preadmission Screening for Elective Admissions 

Requested Screening: 
Admission Concurrent/Rehab Conversion/Rehab Rereview 
Submit pgs. 1, 2, & 6. Submit pgs. 3 & 6. Submit pgs. 1, 4, & 6. Submit pg. 5. 
(: ai) Unchecked
(: c2) Unchecked
(: d1) Unchecked
(: fa1) Unchecked
Member (Patient) Information 

Member ID: 
(Member ID:) 
Member name: 
(Member name:) 
DOB: 
(DOB:) 
Gender: M F 
(checkbox) Unchecked
(checkbox) Unchecked
Address: 
(Address:) 
Guardian: 
(Guardian:) 
Guardian address: 
(Guardian address:) 


Requesting Provider Information 

Provider ID/Service Location: 
(ID/LOC:) 
or NPI: 
(or NPI:) 
Specialty: 
(Specialty:) 
Address: 
(Address:) 
Contact name: 
(Contact name:) 
Tel. no.: 
(Tel. no.:) 
Fax: 
(Fax:) 
Name of physician contact for peer-to-peer discussion: 
(Name of physician contact for peer-to-peer discussion:) 
Tel. no.: 
(Tel. no.:) 
Availability: 
(Availability:) 


Admitting Facility Information 

Provider ID/Service Location: 
(ID/LOC:) 
or NPI: 
(or NPI:) 
Name: 
(Name:) 
Tel. no.: 
(Tel. no.:) 
Fax: 
(Fax:) 
Address: 
(Address:) 


Attending Physician Information (at the admitting facility) 

Provider ID/Service Location: 
(ID/LOC:) 
or NPI: 
(or NPI:) 
Specialty: 
(Specialty:) 
Attention (contact person for the attending): 
(Attention (contact person for the attending):) 
Name: 
(Name:) 
Tel. no.: 
(Tel. no.:) 
Address: 
(Address:) 


MassHealth/Permedion Acute Preadmission Screening for Elective Admissions | page 1 

PAS-A (Rev. 11/09) 


Admission Screening 

(Be sure to complete pages 1, 2, and 6.) 

 
Acute rehab 
Requested admission date: 
(Date of accident) 
Acute 
Assignment (Admission type): 
(checkbox) Unchecked
(checkbox) Unchecked
(Requested length of stay) 
(Requested admission date) 


 Requested length of stay: 
Accident? 


(checkbox) Unchecked 
Yes 
Fall 
Work 
MV-Pedestrian 
MV-Passenger 
MV-Driver 
(checkbox) Unchecked 
No Date of accident: 
Type of accident:
(checkbox) Unchecked
(checkbox) Unchecked
(checkbox) Unchecked
(checkbox) Unchecked
(checkbox) Unchecked
(Other) 
Other: 
(checkbox) Unchecked
(If yes, reason) 
Out of state? 
Yes 
No If yes, reason: 
Late submission?
(checkbox) Unchecked
(checkbox) Unchecked
(If yes, reason) 
Yes 
No If yes, reason: 
Hospital patient account number (if available): 
(checkbox) Unchecked
(checkbox) Unchecked
(Hospital patient account number (if available) 
Diagnosis Code Diagnosis Description 
Primary Diagnosis 
((Diagnosis Code, Primary Diagnosis)) 
((Diagnosis Description, Primary Diagnosis)) 
Diagnosis 2 
((Diagnosis Code, Diagnosis 2)) 
((Diagnosis Description, Diagnosis 2)) 
Diagnosis 3 
((Diagnosis Code, Diagnosis 3)) 
((Diagnosis Description, Diagnosis 3)) 
Diagnosis 4 
((Diagnosis Code, Diagnosis 4)) 
((Diagnosis Description, Diagnosis 4)) 
Diagnosis 5 
((Diagnosis Code, Diagnosis 5)) 
((Diagnosis Description, Diagnosis 5)) 


Service Code Service Description Service Date 
Primary Service Code 
((Service Code, Primary Service Code)) 
((Service Description, Primary Service Code)) 
((Service Date, Primary Service Code)) 
Service Code 2 
((Service Code, Service Code 2)) 
((Service Description, Service Code 2)) 
((Service Date, Service Code 2)) 
Service Code 3 
((Service Code, Service Code 3)) 
((Service Description, Service Code 3)) 
((Service Date, Service Code 3)) 
Service Code 4 
((Service Code, Service Code 4)) 
((Service Description, Service Code 4)) 
((Service Date, Service Code 4)) 
Service Code 5 
((Service Code, Service Code 5)) 
((Service Description, Service Code 5)) 
((Service Date, Service Code 5)) 


Please describe any clinical indications for admission and/or procedures (e.g., signs, symptoms, or 
test results) that may assist us in our review: 
(text) 



For REHAB, please include the following information: 
(Current medical status) 


Current medical status: 
(Plan of care/goals) 
Plan of care/goals: 
(PT & OT (Please complete page 6 and submit with this form [1]) 
PT and OT (Please complete page 6 and submit with this form.): 
(PT & OT (Please complete page 6 and submit with this form [2]) 


Cognition/SLP: 
(Discharge plan) 
(CD/SLP) 
Discharge plan: 

MassHealth/Permedion Acute Preadmission Screening for Elective Admissions | page 2 


Concurrent Screening (FOR REHAB ONLY) 

(Be sure to complete pages 3 and 6.) 

Current PAS#: 
Hospital name: 
(Hospital name) 
Member name: 
(Member name) 
Requested level of care (LOC): Acute w/rehab administrative days (AD) 
Acute w/rehab hospital level of care (HLOC) 
Requested from date: 
(Requested from date) 
Requested additional length of stay (LOS): 
(Requested additional length of stay (LOS) 
(checkbox) Unchecked
Late request? Yes No 
(checkbox) Unchecked
If yes, reason: 
(If yes, reason) 



(checkbox) Unchecked
(checkbox) Unchecked
(Current PAS) 
Physician contact for peer-to-peer discussion: 
(Tel. no) 
(Name) 
Name: 
(Availability) 


 Tel. no.: 
Availability: 

Clinical Information 
(Discharge plan) 


Discharge plan: 
(Barriers to discharge) 
Barriers to discharge: 
(Weekly team meeting results) 
Weekly team meeting results: 
(Estimated discharge date) 
Estimated discharge date: 
(Assistance with discharge planning requested from MassHealth [1]) 
Assistance with discharge planning requested from MassHealth: 
(Assistance with discharge planning requested from MassHealth [2]) 


Please describe any additional clinical indications (e.g., signs, symptoms, or test results) and/or 
procedures (treatments, wound measurements and descriptions, etc.) for extending the stay that 
may assist us in our review: 
(text) 



Please include information on the continued plan of care/goals for the following: 
(PT & OT (Please complete page 6 and submit with this form [1]) 


PT and OT (Please complete page 6 and submit with this form.): 
(PT & OT (Please complete page 6 and submit with this form [2]) 


Cognition/SLP: 
(CD/SLP) 


MassHealth/Permedion Acute Preadmission Screening for Elective Admissions | page 3 


Conversion Review (FOR REHAB ONLY) 

(Be sure to complete pages 1, 4, and 6) 

Reason for conversion: 
(Requested length of stay) 
(Date of conversion) 
(Admission date) 
(Reason for conversion) 
Admission date: 

 Date of conversion: 

 Requested length of stay (LOS): 
Assignment/Requested level of care (LOC): 


(checkbox) Unchecked
Acute w/Rehab administrative days (AD) 
Acute w/Rehab hospital level of care (HLOC) 
(checkbox) Unchecked
(checkbox) Unchecked
(checkbox) Unchecked
(Date of accident) 


Accident? Yes No Date of accident: 
Type of accident: MV-Driver 
(checkbox) Unchecked 
MV-Passenger
(checkbox) Unchecked 
MV-Pedestrian 
(checkbox) Unchecked 
Work
(checkbox) Unchecked 
Fall
(checkbox) Unchecked 
Other: 
(checkbox) Unchecked
(Other) 
Out of state? Yes 
(checkbox) Unchecked 
No 
(checkbox) Unchecked
If yes, reason: 
(If yes, reason) 
Late submission? Yes 
(checkbox) Unchecked 
No 
(checkbox) Unchecked
If yes, reason: 
(If yes, reason) 


Hospital patient account number (if available): 
(Hospital patient account number (if available) 


Diagnosis Code Diagnosis Description 
Primary Diagnosis 
((Diagnosis Code, Primary Diagnosis)) 
((Diagnosis Description, Primary Diagnosis)) 
Diagnosis 2 
((Diagnosis Code, Diagnosis 2)) 
((Diagnosis Description, Diagnosis 2)) 
Diagnosis 3 
((Diagnosis Code, Diagnosis 3)) 
((Diagnosis Description, Diagnosis 3)) 
Diagnosis 4 
((Diagnosis Code, Diagnosis 4)) 
((Diagnosis Description, Diagnosis 4)) 
Diagnosis 5 
((Diagnosis Code, Diagnosis 5)) 
((Diagnosis Description, Diagnosis 5)) 


Service Code Service Description Service Date 
Primary Service Code 
((Service Code, Primary Service Code)) 
((Service Description, Primary Service Code)) 
((Service Date, Primary Service Code)) 
Service Code 2 
((Service Code, Service Code 2)) 
((Service Description, Service Code 2)) 
((Service Date, Service Code 2)) 
Service Code 3 
((Service Code, Service Code 3)) 
((Service Description, Service Code 3)) 
((Service Date, Service Code 3)) 
Service Code 4 
((Service Code, Service Code 4)) 
((Service Description, Service Code 4)) 
((Service Date, Service Code 4)) 
Service Code 5 
((Service Code, Service Code 5)) 
((Service Description, Service Code 5)) 
((Service Date, Service Code 5)) 


Clinical Information 
Please describe any clinical indications for admission and/or procedures (e.g., signs, symptoms, or test results) 
that may assist us in our review. Include past medical history and plan of care: 
(text) 



Please include the following information: 
(PT & OT (Please complete page 6 and submit with this form [1]) 


PT and OT (Please complete page 6 and submit with this form.): 
(PT & OT (Please complete page 6 and submit with this form [2]) 


Cognition/SLP: 
(Goals) 
(CD/SLP) 
Goals: 
(Discharge plan) 
Discharge plan: 

MassHealth/Permedion Acute Preadmission Screening for Elective Admissions | page 4 


Rereview 


 
Extension of rehab admit 
Requested from date: 
Requested additional length of stay (LOS): 
Late request?
(Requested additional length of stay (LOS) 
(If yes, reason) 
Rehab admit 
Acute admit
Current PAS#: 
(Hospital name) 
(Current PAS) 
Hospital name: 
(Member name) 
Member name: 
Requested level of care: 
(checkbox) Unchecked
(checkbox) Unchecked
(checkbox) Unchecked
(Requested from date) 



(checkbox) Unchecked 
Yes 
(checkbox) Unchecked 
No If yes, reason: 
Please identify and address all decisions in the Admission Determination Notice with which you disagree, 
and submit all additional information and documentation to support the medical necessity of the admission. 
(text) 



To facilitate physician-to-physician conversation: 

I certify that I am the Requesting Provider/Attending Physician/Authorized Representative of the Admitting 
Facility (circle one) identified on this form. I certify that the information provided on this form and on any 
attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete 
to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for 
any falsification, omission, or concealment of any material fact contained herein. 

Name of physician the Permedion physician should contact: 
(Tel no) 
(Name of physician the Masspro physician should contact) 
Tel no.: 
(Availability) 
Availability: 


MassHealth/Permedion Acute Preadmission Screening for Elective Admissions | page 5 


PT and OT Information 


Physical Therapy 

Current Status 
Treatment Plan 
(also specify hours per day) 
Goals 
Assistive devices: 
(e.g., cane/crutches/walker/ 
rolling walker/wheelchair) 
((Current Status, Assistive devices: (e.g., cane/crutches/walker/ rolling walker/wheelchair))) 
((Treatment Plan (also specify hours per day), Assistive devices: (e.g., cane/crutches/walker/ rolling walker/wheelchair))) 
((Goals, Assistive devices: (e.g., cane/crutches/walker/ rolling walker/wheelchair))) 
Bed mobility 
((Current Status, Bed mobility)) 
((Treatment Plan (also specify hours per day), Bed mobility)) 
((Goals, Bed mobility)) 
Sitting/standing balance 
((Current Status, Sitting/standing balance)) 
((Treatment Plan (also specify hours per day), Sitting/standing balance)) 
((Goals, Sitting/standing balance)) 
Transfers: 
•Bed to chair 
•Bathroom 
((Current Status, Transfers: Bed to chair Bathroom)) 
((Treatment Plan (also specify hours per day), Transfers: Bed to chair Bathroom)) 
((Goals, Transfers: Bed to chair Bathroom)) 
Ambulation–Distance 
((Current Status, Ambulation: Number of feet)) 
((Treatment Plan (also specify hours per day), Ambulation: Number of feet)) 
((Goals, Ambulation: Number of feet)) 


Occupational Therapy 

Current Status 
Treatment Plan 
(also specify hours per day) 
Goals 
Cognitive skills 
((Current Status, Cognitive skills)) 
((Treatment Plan (also specify hours per day), Cognitive skills)) 
((Goals, Cognitive skills)) 
Activities of daily living 
((Current Status, Activities of daily living)) 
((Treatment Plan (also specify hours per day), Activities of daily living)) 
((Goals, Activities of daily living)) 
Fine motor skills 
((Current Status, Fine motor skills)) 
((Treatment Plan (also specify hours per day), Fine motor skills)) 
((Goals, Fine motor skills)) 
Gross motor skills 
((Current Status, Gross motor skills)) 
((Treatment Plan (also specify hours per day), Gross motor skills)) 
((Goals, Gross motor skills)) 
Sensory processing 
((Current Status, Sensory processing)) 
((Treatment Plan (also specify hours per day), Sensory processing)) 
((Goals, Sensory processing)) 
Social skills 
((Current Status, Social skills)) 
((Treatment Plan (also specify hours per day), Social skills)) 
((Goals, Social skills)) 


Please include any additional information in the space below: 
(text) 



I certify that I am the Requesting Provider/Attending Physician/Authorized Representative of the Admitting 
Facility (circle one) identified on this form. I certify that the information provided on this form and on any 
attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete 
to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for 
any falsification, omission, or concealment of any material fact contained herein. 

MassHealth/Permedion Acute Preadmission Screening for Elective Admissions | page 6