MassHealth/Masspro Telephone: 1-800-554-5127 Fax: 1-800-752-6334 
Chronic/Rehab 

Preadmission Screening 

Member (Patient) Information 
Member ID: 
 Member name: 
 
DOB: 
 Gender: M F OffOff
 
Address:  
 
Guardian:  
 
Guardian address:  
 

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

Admitting Facility Information 
Provider ID/Service Location: 
 or NPI: 
 
Name: 
 
Tel. no.: 
 Fax:  
 
Address: 
 

Attending Physician Information (at the admitting facility) 
Provider ID/Service Location: 
 or NPI: 
 
Specialty: 
 
Attention (contact person for the attending):    
 
Name: 
 Tel. no.:  
 
Address: 
 

MassHealth/Masspro Chronic/Rehab Preadmission Screening  | page 1 
PAS-CR (05/15/09) 
(Be sure to complete pages 1, 2, and 6.) 

   Rehab Requested admission date:  


   Chronic Assignment (admission type): OffOff


   Requested length of stay (LOS):  Accident?  

Off
   Yes    

   Fall 

   Work

   MV-Pedestrian 

   MV-Passenger

   MV-Driver 

Off
   No  Date of accident:  Type of accident:OffOffOffOffOff



   Other:  Off

Out of state?

   Yes    

   No  If yes, reason:  Late submission?
OffOff



   Yes    


   No  If yes, reason:  Hospital patient account number (if available):  
OffOff



Diagnosis Code  Diagnosis Description  
Primary Diagnosis  
 
 
Diagnosis 2  
 
 
Diagnosis 3  
 
 
Diagnosis 4  
 
 
Diagnosis 5  
 
 

Service Code  Service Description  Service Date  
Primary Service Code  
 
 
 
Service Code 2  
 
 
 
Service Code 3  
 
 
 
Service Code 4  
 
 
 
Service Code 5  
 
 
 

Clinical Information 
Ventilator dependent?   

Off
   Yes    

Off
   No TBI? 

Off
   Yes    

Off
   No Tracheotomy?  

Off
   Yes    

Off
   No    

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 treatment/course of care at  the acute facility: 


For REHAB, please include the following information: 

Current medical status:  

Plan of care/goals:  

PT and OT (Please complete page 6 and submit with this form.):  


Cognition/SLP: 
Discharge plan:  
MassHealth/Masspro Chronic/Rehab Preadmission Screening  | page 2 

Concurrent Screening 
(Be sure to complete pages 3 and 6.) 
Current PAS#:  

Hospital name:  

Member name: 
Requested level of care (LOC):  

Off
   Chronic hospital level of care (HLOC)
Off
   Rehab hospital level of care (HLOC)   Chronic/Rehab administrative days (AD) Off

Requested from date:  

   Requested additional lengh of stay (LOS):  Late request? 
Off
   Yes    Off
   No  If yes, reason:  
Physician contact for peer-to-peer discussion: 

Name:      Tel. no.:   
Availability:  
 
Clinical Information Ventilator dependent?   Discharge plan:  Barriers to discharge:      Yes    Off
    No Off
 TBI?     Yes    Off
    No Off
 Tracheotomy?  
OffOff
    Yes        No     

Weekly team meeting results:  

Estimated discharge date:  

Assistance with discharge planning requested from MassHealth:  


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:  



For REHAB, please include information on the continued plan of care/goals for the following: 

PT and OT (Please complete page 6 and submit with this form.):  

Cognition/SLP: 
Goals: 
MassHealth/Masspro Chronic/Rehab Preadmission Screening  | page 3 
(Be sure to complete pages 1, 4, and 6.) 
Reason for conversion:  
Admission date:  
   Date of conversion: 
   Requested length of stay (LOS):  Assignment/Requested level of care (LOC):  

Off
   Chronic hospital level of care (HLOC) 

Off
   Rehab hospital level of care (HLOC) 


Off
   Chronic/Rehab administrative days (AD) Accident?  

Off
   Yes    

Off
   No  Date of accident:  Type of accident:


Off
   MV-Driver 

Off
   MV-Passenger

Off
   MV-Pedestrian 

Off
   Work

Off
   Fall 

Off

   Other:  Out of state?

Off
   Yes    

Off
   No  If yes, reason:  Late submission?


Off
   Yes    


Off
   No  If yes, reason:  Hospital patient account number (if available):  



Diagnosis Code  Diagnosis Description  
Primary Diagnosis  
 
 
Diagnosis 2  
 
 
Diagnosis 3  
 
 
Diagnosis 4  
 
 
Diagnosis 5  
 
 

Service Code  Service Description  Service Date  
Primary Service Code  
 
 
 
Service Code 2  
 
 
 
Service Code 3  
 
 
 
Service Code 4  
 
 
 
Service Code 5  
 
 
 

Clinical Information 
Ventilator dependent?   

Off
   Yes    

Off
   No TBI? 

Off
   Yes    

Off
   No Tracheotomy?   

Off
   Yes    

Off
   No    
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: 

For REHAB, please include the following information: 

PT and OT (Please complete page 6 and submit with this form.):  

Cognition/SLP: 
Goals: 
Discharge plan:  
MassHealth/Masspro Chronic/Rehab Preadmission Screening  | page 4 

   Administrative days (AD) 
Requested from date:  
Requested additional length of stay (LOS):  
Late request?



   Rehab 

   Chronic
Current PAS#:  

Hospital name:  

Member name: 
Requested level of care:  
OffOffOff



Off
   Yes    

Off
   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. 


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 Masspro physician should contact:  

Tel no.:  

Availability:  

MassHealth/Masspro Chronic/Rehab Preadmission Screening  | page 5 
Physical Therapy 
Current Status  Treatment Plan (also specify hours per day)  Goals  
Assistive devices: (e.g., cane/crutches/walker/ rolling walker/wheelchair)  
 
 
 
Bed mobility  
 
 
 
Sitting/standing balance  
 
 
 
Transfers: •Bed to chair •Bathroom  
 
 
 
Ambulation–Distance  
 
 
 

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

Please include any additional information in the space below: 


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/Masspro Chronic/Rehab Preadmission Screening  | page 6