MMIS LTC SCREENING
The tables below display the ALT2, ALT3, ALT4, ALT5 and ALT6 panels of the MMIS LTC SCREENING in MMIS.
ALT2-6 panels use the same navigation tools as detailed for the ALT1 panel on the previous page of this course.
In these tables MMIS fields are populated with sample data to show how MMIS fields appear with valid values entered. Field entries containing Protected Health Information (PHI) appear as zeros in these examples.
Table of MMIS LTC SCREENING - ALT2 panel
NEXT: ALT3 MMIS LTC SCREENING - ALT2
DOCUMENT NBR: 0000 000 0 000
DOC STAT: A APPROVED LAST FIRST I 00000000 AGE/LA: 000 00
PRESENT AT SCRNG: 01 CLIENT 04 SOC WRKR 05 NURSE 13 CONS GUARD
MARITAL STATUS: 01 SINGLE REASONS FOR REF: 09 REQ RELOC
CURRENT LA: 04 CONGREGATE PLANNED LA: 01 ALONE TEAM: 04 HOSP TRNF:
OBRA LVL 1 SCR: Y PAS 30 DAY: N
CURR HOUSING: 09 OWN HOME
PLANNED HSNG: 09 OWN HOME
CURR PGM LIC: 09 NONE OBRA LVL 2 REF - MI DX: Y DD DX: Y
PLAN PGM LIC: 09 NONE TBI/CAC REF: N
LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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Table of the MMIS LTC SCREENING - ALT3 panel
NEXT: ALT4 MMIS LTC SCREENING - ALT3
DOCUMENT NBR: 0000 000 0 000
DOC STAT: A APPROVED LAST FIRST I 00000000 AGE/LA: 000 00
DRESSING: 02 GROOMING: 02 BATHING: 04 EATING: 02 BED MOB: 00
TRANSFER: 00 WALKING: 01 BEHAVIOR: 04 TOILET: 01 SPC TRMT: 00
CL MONITOR: 00 NEURO DX: N CASE MIX: E ORIENT: 01 SLF PRES: 04
DIS CERT: 01 SLF EVAL: 03 HEARING: 01 COMM: 01 VISION: 01
MENT ST EV: 30 TEL ANS: 01 TEL CALL: 02 SHOPPING: 03 PREP MLS: 03
LT HOUSE: 03 HY HOUSE: 04 LAUNDRY: 03 MGMT MEDS: 03 INSULIN: 01
MONEY MT: 04 TRANSP: 04 FALLS: 01 HOSP: 01 ER VISITS: 01
NF STAYS: 01
LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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Table of the MMIS LTC SCREENING - ALT4 panel
NEXT: ALT5 MMIS LTC SCREENING - ALT4
DOCUMENT NBR: 0000 000 0 000
DOC STAT: A APPROVED LAST FIRST I 00000000 AGE/LA: 000 00
ASSESSMENT RESULTS/EXIT RSNS: 02 COMM N/WVR EFFECTIVE DT: 050109
INFORMED CHOICE: Y
CLIENT CH: 02 COMM N/WVR GUARDIAN CH: 02 COMM N/WVR FAM CH: 02 COMM N/WVR
LTCC/IDT RECMND: 02 COMM N/WVR LVL OF CARE: 02 NF NF TRACK:
CASE MIX AMT: CASE MIX APP (Y/N):
REASONS FOR INSTITUTIONAL STAY:
ADL COND: Y IADL COND: Y COMP COND: N COGNITION: Y BEHAVIOR: Y
HYG/SAFETY: Y NEG/ABUSE: N FRAILTY: Y INST STAYS: Y HEARING IMP: Y
REST/REHAB: Y UNSTABLE: N SPEC TREAT: N CMPLX CARE: N VISUAL IMP: Y
REQUIRES AC/WVR SVC: Y SAFE/COST EFFECTIVE: Y NO OTHER PAYOR IS RESP: N
PROGRAM TYPE: 00 NONE MNDHO RCC: CDCS: N CDCS AMOUNT:
LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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Table of the MMIS LTC SCREENING - ALT5 panel
NEXT: ADHS MMIS LTC SCREENING - ALT5
DOCUMENT NBR: 0000 000 0 000
DOC STAT: A APPROVED LAST FIRST I 00000000 AGE/LA: 000 00
CODE IND DESCRIPTION CODE IND DESCRIPTION
38 F RELOCATION SVC COORDINATION 30 F NOT RECEIVING FORMAL SERVICES
07 I MONEY MANAGEMENT
LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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The ALT6 panel displays only when recipient is on the AC (Alternative Care) program.
Table of the MMIS LTC SCREENING - ALT6 panel
NEXT: ADHS 06/08/09 07:52:13 MMIS LTC SCREENING - ALT6 X124422 03/12/09 PWMW949
DOCUMENT NBR: 0000 000 0 000
DOC STAT: A APPROVED LAST FIRST I 00000000 AGE/LA: 000 00
STREET ADDRESS: 100 MAIN ST
STREET ADDRESS: APT. #
CITY: ANYTOWN STATE: MN ZIP CODE: 00000 CFR: 000
GROSS INCOME: 0000 GROSS ASSETS: 000
AC ADJUSTED INCOME: 0000 AC ADJUSTED ASSETS: 000
MEDICARE ID NUMBER: 0000000000
MEDICARE PART A BEGIN DT: MM/DD/YY END DT: 99/99/99
MEDICARE PART B BEGIN DT: MM/DD/YY END DT: 99/99/99
AC FEE WAIVER REASON: 06 INC LT MIN MED ELIGIBLE: Y AC FEE ASSESSED: N
LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID LI EXC ST USER ID
00 389 6
389 THE MEDICARE DATA WILL NOT CHANGE OR REPLACE THE MEDICARE DATA ON THE
RECIPIENT FILE.
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12
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