Get Pa Dhs Ma 103 2015
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How to fill out the PA DHS MA 103 online
The Pennsylvania Department of Human Services Medical Assistance Admission & Discharge Transmittal (MA 103) is essential for documenting the admission and discharge of residents in long-term care facilities. This guide provides a step-by-step approach to successfully complete the MA 103 online.
Follow the steps to complete the MA 103 form effectively.
- Click ‘Get Form’ button to access the MA 103. This action allows you to open the form for completion.
- Begin by tearing off the top instruction sheet, which will guide you through completing the MA 103 correctly.
- In the Resident Data section, accurately fill in the resident’s name (last, first, middle initial), Access Number, Social Security Number, Birthdate, Sex, and County. Ensure all numbers are formatted correctly, using six-digit format and zero-filling as necessary.
- Next, indicate the Type of Service for which payment is currently authorized by checking the appropriate box and providing details if the category is marked 'Other'.
- Record the Admission Date to Facility in the required format and complete the Short Term Stay section, if applicable, by indicating the recommended length of stay.
- In the Provider Data section, input the Facility Name, Service Provider ID-Service Location, Attending Physician, and Physician Number. Verify that the facility name matches the MA Provider Notice.
- Move to the Discharge Planning Data section to document the Date of Current Discharge Plan and confirm whether the discharge plan includes necessary items (a-f). Address any 'No' responses in the Comments section.
- Complete the Change of Care Recommendations section by marking the appropriate box for the type of care recommended and explaining the resident’s condition.
- In the Transfer/Discharge section, mark the Discharge Codes relevant to the resident’s situation. If applicable, provide explanations for the selected codes.
- Ensure that a 30-Day Notice of Discharge is marked and the date it was sent is properly recorded.
- Lastly, have the administrator or designee sign and date the form to validate the information. Keep the original for the resident’s clinical record and send the copy labeled 'County Assistance Office' to the CAO within three days.
- Once all sections are filled out accurately, you can save, download, or print the completed form as needed.
Complete your documents online accurately and efficiently to ensure proper processing.
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The approval time for medical assistance in Pennsylvania can vary based on several factors, including the completeness of your application and the current processing workload of the PA DHS. Generally, you can expect a decision within 30 days after submitting your MA 103 form, provided there are no complications. Staying organized and providing all required information can help expedite the process.
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