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Please complete the notification form when making a referral for a direct admit and provide to NWMHP

|Referral Coordinator: |Location being admitted to SNF From: |

| | |

|Patient Last Name |First Name |DOB |

|Primary Care Physician Name |Office Group |

|Verification of SNF Waiver Necessity (please refer to back for explanation): |

|Has NOT had at least 3 consecutive calendar days of inpatient care in the past 30 days |

|Has NOT discharged from a SNF in past 30 days following a qualifying hospital stay |

|Current condition is NOT related to the previous hospitalization |

|Coverage: □ NextGen ACO – Eligibility of Beneficiary Verified - source: _________________________________________________ |

|Primary Diagnosis: |Secondary Diagnoses: |

| | |

| | |

|Primary Reason for Direct Admission: |Secondary Reason for Direct Admission |

| | |

|□ Fall or Fall Related |□ Fall or Fall Related |

|□ Pain Management (non-fall related) |□ Pain Management (non-fall related) |

|□ Urinary Tract Infection (UTI) |□ Urinary Tract Infection (UTI) |

|□ Wound Care |□ Wound Care |

|□ Dizziness / Unsteadiness |□ Dizziness / Unsteadiness |

|□ Respiratory Problem |□ Respiratory Problem |

|□ Post-surgical – joint replacement |□ Post-surgical – joint replacement |

|□ Post-surgical – other __________________________________ |□ Post-surgical – other ____________________________________ |

|□ Post-stroke care |□ Post-stroke care |

|□ Weakness |□ Weakness |

|□ Dehydration |□ Dehydration |

|□ Cardiac Condition |□ Cardiac Condition |

|□ Gait Instability |□ Gait Instability |

|□ Fall or Fall Related |□ Fall or Fall Related |

|□ Other: ____________________________________________ |□ Other: ____________________________________________ |

|Eligible Contracted Facilities |Date of Direct SNF Admission: |

| | |

| | |

|Life Care Center of Lewiston | |

|Prestige of Clarkston | |

|Cascadia of Lewiston | |

|Avalon Pullman | |

| |Name of SNF: |

| |Checklist of Items for SNF Admission |

| | |

| |□ Completed and signed orders |

| |□ POST and or Advance directives (if available) ( Current Medication list |

| |□ PASSR ( H&P/or current visit note |

| |□ Hard Rx for all schedule II drugs with 7 day supply |

|Beneficiary Facility Preferences: |

| |

|1. ________________________________ 2. ____________________________________ 3. ______________________________ |

| |

| |

|Signature: |

|Date: |

Please fax completed form to:

NWMHP

Attention: Post-Acute Care Coordinator

360-786-8751

SNF Direct Admission Waiver

General Guidelines for Medicare Beneficiary Coverage for SNF Admissions:

Medicare beneficiaries are entitled to the hospital insurance program which covers post-hospital extended care services. To qualify for the coverage under Medicare, the beneficiary must have been inpatient for a medically necessary stay of at least 3 consecutive calendar days.

Time spent in observation or in the emergency room prior to an inpatient admission does not count toward the 3-day consecutive calendar days.

Medicare beneficiaries may access their benefit for skilled nursing facility coverage IF they are transferred to a participating SNF within 30 days after discharge from the hospital. To access the benefit post-discharge 30 day period, the beneficiary must be admitted to the SNF related to the condition that was treated during the qualifying hospital stay.

Beneficiaries may also activate their benefit within 30 days post-discharge from a SNF. If a beneficiary discharges home and is identified to need further skilled care services for the same condition of the qualifying hospital inpatient stay, the beneficiary may be readmitted to the SNF under Medicare Part A services.



If beneficiary has had a qualifying hospital stay and meets the 30 days post-discharge criteria – utilization of the direct admission waiver is not indicated.

Verification of Qualification

1. Verify beneficiary alignment with NGACO

2. Beneficiary meets skilled nursing facility admission criteria

3. Does not meet the general admission requirements for Medicare Part A services

Verification of Participation Agreement with SNF Provider

1. Verification of accepting facility is contracted with NWMHP for utilization of Direct SNF Waiver and is able to meet the needs of the beneficiary

2. SNF is aware that beneficiary is admitted based on waiver utilization

NWMHP Notification of SNF Direct Admission

1. Complete and send to NWMHP via secure email or fax information regarding direct admission data sheet

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