Enrollment/Eligibility
What is the age of eligibility?
What is 55 years or older?
What (3) disciplines are required to complete the following assessments: semi-annual, initial, change of condition?
What are PCP, RN, and MSW?
What is knowingly submitting or causing to be submitted false claims to get a federal health care payment?
What is fraud?
True or False: A stage 3 pressure injury is a trigger event.
What is true. A stage 3 or higher pressure injury is a trigger event.
How can a PACE staff member receive a grievance?
What is verbally or in writing?
What counties does PNW PACE Partners accept enrollees in?
What is Pierce and South King counties?
How many days after an in-person assessment must careplanning occur?
What is 30 days?
What is the practice that result in unnecessary Medicare program cost?
What is abuse?
True or False: A 2nd degree or higher burn is a trigger event.
What is true.
What is the timeframe for responses to, and resolution of, appeals after an appeal is received?
What is as expeditiously as the participant's health condition requires, but no later than 30 calendar days?
What level of care must someone meet to be eligible for PACE?
What is nursing facility level of care?
What disciplines are required to complete in-person assessments for the initial plan of care?
What are the 8 disciplines: PCP, MSW, RN, PT, OT, RD, AC, HCC?
What is the practice that results in unnecessary Medicare program costs?
What is waste?
True or False: A PPT elopement from a skilled nursing facilitiy is a trigger event.
What is true. PACE is responsible for addressing elopements from all settings.
How long does a participant or their designated representative have to initiate an appeal?
What is 20 calendar days from the day they are notified of the denial/reduction (verbally or in writing, whichever happens first)?
When is a participant's enrollment in the program effective?
What is on the first day of the calendar month following the date the PACE organization receives the signed enrollment agreement?
What is the maximum timeframe for the IDT to complete in-person assessments and complete (review and revise) the care plan for unscheduled reassessments (change in condition/status)?
What is 14 calendar days?
Who is our pharmacy benefits manager (PBM)?
What is Pharmastar, now called AnewHealth?
True or False: A medication error without adverse affects is a trigger event.
What is false. All medication errors should be captured in HeRO and are uploaded quarterly with other quality data, but is not a trigger event.
Who can receive the information from a PPT or their DR on an appeal?
What is any PACE staff member? This does not need to be an Interdisciplinary Team (IDT) member.
If a prospective participant is denied enrollment, the PACE organization must notify which agencies?
What are CMS and the State administering agency (SAA)?
CMS= Center for Medicare and Medicaid Services
Our SAA is DSHS.
What state assessment is reviewed and incorporated/aligned with in the plan of care?
What is the CARE assessment?
If a prescriber is no longer allowed, by law, to write scripts and is still writing scripts, what is this an example of?
What is fraud?
True or False: Allegations or abuse or neglect are trigger events.
What is true. All suspected abuse and/or allegations of abuse should be reported to leadership.
After an individual has exhausted the internal appeal process, they have the right to an external appeal through what agency?
What is Medicare or Medicaid?