DMAS-97A/B Form PDF Details

Understanding the DMAS-97A/B form is essential for anyone involved in the field of healthcare, especially for those providing or receiving Medicaid services. This form serves as a comprehensive plan of care for individuals under agency-directed or consumer-directed services, emphasizing the importance of customized care plans tailored to the unique needs of each Medicaid recipient. It meticulously outlines the tasks and the amount of time allocated for each, varying from activities of daily living (ADLs) to instrumental activities of daily living (IADLs), critical for maintaining a person's independence. Tasks include bathing, dressing, medication supervision, meal preparation, and more, with each activity carefully timed to the nearest 15 minutes for precision. Additionally, the form accommodates for special maintenance such as vital signs monitoring and wound care, crucial for individuals with more complex health needs. The documentation process is designed to ensure that the care provided does not exceed the maximum weekly hours based on the recipient's level of care (LOC), which is determined by their capability to perform daily activities and their medical needs. The form also outlines procedures for making changes to the plan of care, giving recipients the right to appeal changes they disagree with, ensuring their participation in the decision-making process regarding their own care. Overall, the DMAS-97A/B form is a vital tool in facilitating effective communication between providers, recipients, and Medicaid, ensuring that care is both adequate and appropriate.

QuestionAnswer
Form Name DMAS-97A/B Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names dmas 97 ab, dmas 97, dmas 97 a and b, dmas 97ab form plan of care

Form Preview Example

AGENCY OR CONSUMER DIRECTION PROVIDER PLAN OF CARE

Agency-Directed Services

Consumer-Directed Services

ASSESSMENT DATE: ___________

 

 

 

 

 

 

 

Recipient:

 

 

 

Medicaid ID#:

 

 

Provider:

 

 

 

 

Provider ID#:

 

 

 

DD WAIVER: WRITE THE AMOUNT OF TIME FOR EACH TASK TO THE NEAREST 15 MINUTES

 

Categories/Tasks

Monday

Tuesday Wednesday Thursday

Friday

Saturday

Sunday

1.ADL’s

Bathing

Dressing

Toileting

Transfer

Assist Eating

Assist Ambulate

Turn/Change Position

Grooming

Total ADL Time:

2.Special Maintenance Vital Signs

Supervise Meds

Range of Motion

Wound Care

Bowel/Bladder Program

Total Maint. Time:

3.Supervision Time

4.IADLS

Meal Preparation

Clean Kitchen

Make/Change Beds

Clean Areas Used by Recipient

Shop/List Supplies

Laundry

(CD only) Money Management

Medical Appointments

Work/School/Social

Total IADLS Time:

TOTAL DAILY TIME:

This Section Must Be Completed in its Entirety for Agency- & Consumer-Directed Services

Composite ADL Score = (The sum of the ADL ratings that describe this recipient.)

BATHING SCORE

TRANSFERRING SCORE

 

Bathes without help or with MH only

0

Transfers without help or with MH only

0

Bathes with HH or with HH & MH

1

Transfers w/ HH or w/HH & MH

1

Is bathed

2

Is transferred or does not transfer

2

DRESSING SCORE

EATING SCORE

 

Dress without help or with MH only

0

Eats without help or with MH only

0

Dresses with HH or with HH & MH

1

Eats with HH or HH & MH

1

Is dressed or does not dress

2

Is fed: spoon/tube/etc.

2

AMBULATION SCORE

CONTINENCY SCORE

 

Walks/Wheels without help w/MH only

0

Continent/incontinent < wkly self care of internal

 

Walks/Wheels w/ HH or HH & MH

1

/external devices

0

Totally dependent for mobility

2

Incontinent weekly or > Not self care

2

LEVEL OF CARE

(LOC)

A (Score 0 - 6)

B (Score 7 - 12)

 

C (Score 9 + wounds, tube feedings, etc.)

Maximum Hours of 25/Week

Maximum Hours 30/Week

Maximum Hours 35/Week

D

Exceeds 35 Hours per Week

 

E

 

Exceptions by Department

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Recipient:

 

Medicaid ID#:

Provider:

 

Provider ID#:

Initial Plan of Care hours must be pre-authorized & should not exceed the maximum for the specified LOC category.

Documentation must support the amount of hours provided to the recipient.

Reason Plan of Care Submitted: New Admission

In Hours

In Hours

Transfer

Reason for change/additional instructions for the aide:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Backup Plan (Person’s name) for CD Services:

 

 

 

 

 

 

 

 

 

 

 

Total Weekly

 

 

 

 

 

 

Plan of Care Effective Date:

 

 

 

Hours:

 

 

 

 

 

 

Recipient / Care Giver Signature:

 

 

 

 

 

 

 

Date:

 

RN or SF Signature

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

Instructions for the DMAS-97A/B (09/05)

 

Provider Notification To Client

This Plan of Care has been revised based on your current needs and available support. If you agree with the changes, no action is required on your part. If you do not agree with the changes, please contact the RN Supervisor who has signed the plan of care to discuss the reason that you disagree with the change.

If the provider agency is unwilling or unable to change the information, and you still disagree, you have the right to an appeal by notifying, in writing, The Appeals Division, The Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, Virginia 23219. The request for an appeal must be filed within thirty (30) days of the time you receive this notification. If you file a request for an appeal before the effective date of this action, ____________ (effective date), services may continue

unchanged during the appeal process.

Instructions for Completion of the DMAS-97A/B

Category/Tasks

FOR DD WAIVER ONLY: Write the amount of time for each task to be done to the nearest 15 minutes. This should be done for each task for each day. Then put the total time for each category, for each day.

OTHER WAIVERS: Place a check mark for each task and put the total time for each category, for each day. Writing the amount of time for each task to the nearest 15 minutes is not necessary, but it greatly assists in the review of authorization requests.

Level of Care Determination For Maximum Weekly Hours

Enter a score for each activity of daily living (ADL) based on the client’s current functioning. Sum each ADL rating & enter the composite score under the appropriate category: A, B, C, D, or E. The amount of time allocated under TOTAL DAILY TIME to complete all tasks MUST NOT EXCEED the maximum weekly hours for the specified LOC of A, B, or C. Check LOC D if the amount of hours per week exceeds 35. Category D can only be used with prior approval from DMAS or the PA contractor. Prior-authorization (PA) must be obtained prior to initiating a change outside the authorized LOC category.

Provider Notification To Client

Anytime the RN Supervisor or Service Facilitator (SF) changes the plan of care that results in a change in the total number of weekly hours, the RN or SF must complete the entire front section of this form. If the change the agency is making does not require PA approval, the RN Supervisor or SF is required to enter the effective date on the Provider Agency Client Notification Section which gives the client their right to appeal. The client should get a copy of both the front and back of the form.

PA Contractor Notification To Client

If the changes to the Plan of Care require PA approval, the entire front portion of this form and the DMAS-98 must be completed and forwarded to PA contractor for approval. If supervision is requested, please remember to attach the Request for Supervision form (DMAS-100). Once received by the PA contractor, the analyst will review the care plan and indicate whether the request is pended, approved, or denied. The recipient will receive by mail the decision letter from the DMAS Fiscal Agent.

Recipient / Care Giver Signature

The recipient’s signature is necessary on the original plan of care and decreases to the hours of care. It is not needed if the hours increase in a new plan of care. The provider may substitute the signature with documentation in the recipient’s record that shows acceptance of the plan of care.

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1. To start off, once filling in the dmas 97ab form plan of care, start in the section containing subsequent blank fields:

dmas 98r completion process described (portion 1)

2. Given that the previous array of fields is complete, you're ready to include the necessary specifics in CategoriesTasks ADLs, Vital Signs Supervise Meds Range, Supervision Time IADLS, Meal Preparation Clean Kitchen, This Section Must Be Completed in, Composite ADL Score The sum of, BATHING SCORE, TRANSFERRING SCORE, Bathes without help or with MH, Dress without help or with MH only, DRESSING SCORE, Transfers without help or with MH, EATING SCORE, and Eats without help or with MH only so that you can move forward to the third part.

The right way to prepare dmas 98r step 2

3. The next part should be pretty uncomplicated, WalksWheels without help wMH only, LEVEL OF CARE LOC, A Score Maximum Hours of Week, Exceeds Hours per Week, Continentincontinent wkly self, B Score, C Score wounds tube feedings etc, Maximum Hours Week Maximum Hours, Page of DMASAB Revised, and Exceptions by Department - all these empty fields is required to be completed here.

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4. The following paragraph needs your information in the subsequent parts: Recipient Provider, Medicaid ID Provider ID, Initial Plan of Care hours must be, Reason Plan of Care Submitted New, In Hours In Hours, Transfer, Documentation must support the, Reason for changeadditional, Backup Plan Persons name for CD, Plan of Care Effective Date, Recipient Care Giver Signature, RN or SF Signature, Total Weekly Hours, Date, and Date. Make certain to enter all of the requested information to move further.

dmas 98r completion process described (part 4)

5. This form must be finished within this segment. Further there can be found a detailed listing of blank fields that need accurate details to allow your document usage to be faultless: Provider Notification To Client, Instructions for Completion of the, CategoryTasks, FOR DD WAIVER ONLY Write the, Level of Care Determination For, Enter a score for each activity of, Provider Notification To Client, Anytime the RN Supervisor or, PA Contractor Notification To, If the changes to the Plan of Care, Recipient Care Giver Signature, and The recipients signature is.

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