ICF/MR PreAdmission Evaluations and
An ICF/MR PreAdmission
Evaluation is required to be submitted to the Bureau of TennCare for approval
1. A Medicaid Eligible is admitted to an
2. A private-paying
resident of an ICF/MR attains Medicaid Eligible status or applies for Medicaid
eligibility. A new ICF/MR PreAdmission Evaluation is not required when an
individual's financial status changes from Medicaid Eligible to private pay and
then back to Medicaid Eligible within a 90-day time period.
(b) A Transfer Form is required to
be submitted to the Bureau of TennCare for approval when an ICF/MR Eligible
having an approved unexpired ICF/MR PAE transfers from one ICF/MR to another
ICF/MR or from the HCBS MR Waiver Program to an ICF/MR. A Transfer Form is
required to be submitted to the Division of Intellectual Disabilities Services
for approval when an ICF/MR Eligible having an approved unexpired ICF/MR PAE
transfers from an ICF/MR to the HCBS MR Waiver Program.
(c) An approved ICF/MR PreAdmission
Evaluation is valid for ninety (90) calendar days from the ICF/MR PAE Approval
Date. An approved ICF/MR PreAdmission Evaluation that has not been used within
ninety (90) calendar days of the ICF/MR PAE Approval Date can be updated within
365 calendar days of the ICF/MR PAE Approval Date if the physician certifies
that the individual's current medical condition is consistent with that
described in the approved ICF/MR PreAdmission Evaluation. A PAE that is not
used within 365 days of the PAE Approval Date is expired and cannot be
(d) An ICF/MR PreAdmission
Evaluation must include a recent medical history and physical signed by a
physician who is licensed as a doctor of medicine or doctor of osteopathy, or
by a licensed nurse practitioner or physician's assistant. A medical history
and physical performed within 365 calendar days of the ICF/MR PAE Request Date
may be used if the individual's condition has not significantly changed.
Additional medical records (progress notes, office records, discharge
summaries, etc.) may be used to supplement a history and physical and provide
current medical information if changes have occurred since the history and
physical was performed.
ICF/MR PAE must include a psychological evaluation of need for care. Pursuant
to 42 C.F.R. § 456.370(b)
, such evaluation must be performed before
admission to the ICF/MR or authorization of payment, but not more than three
months before admission.
An ICF/MR which has entered into a
provider agreement with the Bureau of TennCare is entitled to receive Medicaid
reimbursement for covered services provided to an ICF/MR Eligible if:
1. The Bureau of TennCare has received an
approvable ICF/MR PreAdmission Evaluation for the individual within ten (10)
calendar days of the ICF/MR PAE Request Date or the physician certification
date, whichever is earlier. The PAE Approval Date shall not be more than ten
(10) days prior to date of submission of an approvable PAE. An approvable PAE
is one in which any deficiencies in the submitted application are cured prior
to disposition of the PAE.
the transfer to an ICF/MR of an individual having an approved unexpired ICF/MR
PreAdmission Evaluation, the Bureau of TennCare has received an approvable
Transfer Form within ten (10) calendar days after the date of the transfer. For
transfer from ICF/MR services to an HCBS MR Waiver program, the transfer form
must be submitted and approved prior to enrollment in the HCBS MR Waiver
3. For a retroactive
eligibility determination, the Bureau of TennCare has received a Notice of
Disposition or Change and has received an approvable request to update an
approved, unexpired ICF/MR PreAdmission Evaluation within thirty (30) calendar
days of the mailing date of the Notice of Disposition or Change. The effective
date of payment for ICF/MR services shall not be earlier than the PAE Approval
Date of the original approved, unexpired PAE which has been updated.
Any deficiencies in a
submitted PAE application must be cured prior to disposition of the PAE to
preserve the PAE submission date for payment purposes.
1. Deficiencies cured after the PAE is denied
but within thirty (30) days of the original PAE submission date will be
processed as a new application, with reconsideration of the earlier denial
based on the record as a whole (including both the original denied application
and the additional information submitted). If approved, the effective date of
PAE approval can be no earlier than the date of receipt of the information
which cured the original deficiencies in the denied PAE. Payment will not be
retroactive back to the date the deficient application was received or to the
date requested in the deficient application.
2. Once a PAE has been denied, the original
denied PAE application must be resubmitted along with any additional
information which cures the deficiencies of the original application. Failure
to include the original denied application may delay the availability of
Medicaid reimbursement for ICF/MR services.
(c) An ICF/MR that admits a Medicaid Eligible
without an approved ICF/MR PreAdmission Evaluation or, where applicable, an
approved Transfer Form does so without the assurance of reimbursement from the
Bureau of TennCare.
Criteria for Medicaid-reimbursed Care in an Intermediate Care Facility for the
Mentally Retarded (ICF/MR)
Eligible Status: The individual must be determined by the Tennessee Department
of Human Services to be financially eligible for Medicaid-reimbursed care in an
Intermediate Care Facility for the Mentally Retarded.
An individual must meet all of the
following criteria in order to be approved for Medicaid-reimbursed care in an
Intermediate Care Facility for the Mentally Retarded:
1. Medical Necessity of Care: Care must be
expected to enhance the individual's functional ability or to prevent or delay
the deterioration or loss of functional ability. Care in an Intermediate Care
Facility for the Mentally Retarded must be ordered and supervised by a
2. Diagnosis of Mental
Retardation or Related Conditions.
3. Need for Specialized Services for Mental
Retardation or Related Conditions: The individual must require a program of
specialized services for mental retardation or related conditions provided
under the supervision of a qualified mental retardation professional (QMRP).
The individual must also have a significant deficit or impairment in adaptive
functioning in one of the following areas: communication, comprehension,
behavior, or activities of daily living (e.g., toileting, bathing, eating,
dressing/grooming, transfer, mobility).
(c) Individuals with mental retardation or
related conditions who were in an Intermediate Care Facility for the Mentally
Retarded or who were in community residential placements funded by the Division
of Intellectual Disabilities on or prior to the effective date of this rule may
be deemed by the Bureau of TennCare to meet the requirements of (4)(b)2. and
(d) For continued Medicaid
reimbursement of care in an Intermediate Care Facility for the Mentally
Retarded, an individual must continue to meet the criteria specified in (4)(a)
and (4)(b), unless otherwise exempted by (4)(c).
(a) A Medicaid Eligible or the legal
representative of the Medicaid Eligible has the right to appeal the denial of
an ICF/MR PreAdmission Evaluation and to request a Commissioner's
Administrative Hearing by submitting a written letter of appeal to the Bureau
of TennCare within thirty (30) calendar days of receipt of the notice of
If the Bureau of
TennCare denies an ICF/MR PreAdmission Evaluation, the individual will be
notified in the following manner:
1. A written
notice of denial shall be sent to the individual and, where applicable, to the
Designated Correspondent. A notice of denial shall also be sent to the ICF/MR.
This notice shall advise the individual of the right to appeal the denial
decision within thirty (30) calendar days. The notice shall also advise the
individual of the right to submit within thirty (30) calendar days either the
original ICF/MR PAE with additional information for review or a new ICF/MR PAE.
The notice shall be mailed to the individual's address as it appears upon the
ICF/MR PAE. If no address appears on the ICF/MR PAE and supporting
documentation, the notice will be mailed to the ICF/MR for forwarding to the
2. If an ICF/MR
PreAdmission Evaluation is resubmitted with additional information for review
and if the Bureau of TennCare continues to deny the ICF/MR PreAdmission
Evaluation, another written notice of denial shall be sent as described in
individual has the right to be represented at the hearing by anyone of their
choice. The hearing will be conducted according to the provisions of the
Tennessee Uniform Administrative Procedures Act.
(d) Reasonable accommodations shall be made
for individuals with disabilities who require assistance with
(e) Any notice required
pursuant to this section shall be a plain language written notice.
Tenn. Comp. R. &
Original rule filed June
22, 2000; effective September 5, 2000. Public necessity rule filed July 1,
2009; effective through December 13, 2009. Amendment filed September 11, 2009;
effective December 10, 2009. Emergency rule filed March 1, 2010; effective
through August 28, 2010. Amendments filed May 27, 2010; effective August 25,
Authority: T.C.A. §§
71-5-105, 71-5-109, and Executive
Order No. 11.