Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA  02111
www.mass.gov/dma	
		MassHealth
		Nursing Facility Bulletin 121
		October 2002

	TO:	Nursing Facilities Participating in MassHealth
	FROM:	Wendy E. Warring, Commissioner

	RE:	Revision of Forms:  Level I PAS (Preadmission Screening), and Request for Services

Background	The Division is updating two of its nursing facility forms in an effort to facilitate communication between nursing facility providers and the Division.	

Revision to Level I	The Level I PAS has been revised.  Effective October 1, 2002, the
Preadmission Screening	Division will accept only the revised form. Before admission, the
Form	nursing facility must complete the Level I PAS for all admissions, 
regardless of payment source.  If the Level I PAS indicates a need for 
Level II PAS, the nursing facility must make a referral to the Department 
of Mental Retardation (DMR) for individuals with mental retardation and/or 
developmental disability.  For individuals with mental illness, a referral to 
a Health and Educational Services (HES)-contracted agent for the 
Department of Mental Health (DMH) must be made. 

Revision to Request for	The Request for Services form (formerly called the MassHealth Long 
Services Form 	Term Care Assessment form for nursing facilities) has been revised.  
	Effective October 1, 2002, the Division or its agent will accept only the 
	Request for Services form.  To determine the applicant’s or member’s 
	clinical eligibility, nursing facilities must complete this form and submit it, 
	with copies of the most recent comprehensive Minimum Data Set (MDS) 
	2.0 and the current quarterly MDS, to your local Aging Services Access 
	Points (ASAPs), the Division’s agent.

Completing the Forms  	A nurse or social worker, licensed by the Massachusetts Board of 
	Registration, must complete the Level I PAS. 

	A registered nurse, licensed by the Massachusetts Board of Registration
	in Nursing, must complete the Request for Services form.

										

Obtaining the  	Copies of the Level I PAS and Request for Services forms are attached.  
MassHealth Forms	You may photocopy the forms as needed.  To obtain supplies of the
	forms, mail or fax a written request to the following address or fax
	number.

		MassHealth
		Forms Distribution
		P.O. Box 9101
		Somerville, MA  02145
		Fax:  617-576-4087	

Effective Date 	You must begin using these forms by October 1, 2002.  Please discard
	all previous versions of these forms. 

Questions	If you have any questions about this bulletin, please contact MassHealth Provider Services at 617-628‑4141 or 1‑800‑325-5231.