MMIS TYPE B HOME CARE SERVICE AGREEMENT - ASA3

The ASA3 panel lists the services that have been authorized. Each line includes the dates the service may be provided and claims paid for. The designated provider of those services and the rate and units prior authorized are also included on each line.

Up to 99 lines may be entered on a service agreement, however only two lines are displayed on the ASA3 panel at a time.

The table below displays lines 01 and 02 on the first screen The remaining lines 03 and 04 follow.

Table of the MMIS SERVICE AGMT - ASA3 panel 
   NEXT: AHC1                 MMIS SERVICE AGMT - ASA3  
                     AUTHORIZATION NBR: 0000 000 0 000                          
 AGMT TYPE/STAT: B A APPROVED     PROV NBR/TYPE:                                
  RECIP NAME/ID: LAST               FIRST    I 00000000 SEX: M AGE/LA:  00 00
  LINENAV: 00                                                             +     
 LI COMMENTS/PROCEDURE DESCRIPTION   PROC    MOD1-4           REV  DRUG  DAANES 
 01                                 T1019    U5                                   
    PCA NOTICE OF REDUCTION 15 MIN           START/END DT: MMDDYY MMDDYY        
    REQ RATE/UNIT:      0.00            REQ TOT UNITS/AMT:         00     000.00
    PROV NBR/NAME: 0000000000  HOME CARE PROVIDER                 SHR/FREQ:   5 
    APP RATE/UNIT:      0.00 SRC: PP   TOT USED UNITS/AMT:    
    STAT CD/DATE: A APPROVED   MMDDYY RSN CD: 555         RFE:   CTY:   RPT:    
 02                                 T1019                                       
    PERSONAL CARE SERVICES, 15 MIN           START/END DT: MMDDYY MMDDYY        
    REQ RATE/UNIT:      0.00            REQ TOT UNITS/AMT:       0000   00000.00
    PROV NBR/NAME: 0000000000  HOME CARE PROVIDER                 SHR/FREQ:   5 
    APP RATE/UNIT:      0.00 SRC: pp   TOT USED UNITS/AMT:    
    STAT CD/DATE: A APPROVED   MMDDYY RSN CD:             RFE:   CTY:   RPT:    
 LI EXC ST USER ID  LI EXC ST USER ID  LI EXC ST USER ID  LI EXC ST USER ID     
 01 274  6                                                                      
 274 RECIPIENT IS ELIGIBLE FOR MEDICARE.  YOU NEED TO CHECK WHETHER             
     THESE SERVICES ARE PAID BY MEDICARE.                                       
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12 
 PAGE  HELP        S/EXT NAVIG SLIST N/EXT PREV  NEXT         OOPS                  
   NEXT: AHC1                MMIS SERVICE AGMT - ASA3  
                     AUTHORIZATION NBR: 0000 000 0 000                          
 AGMT TYPE/STAT: B A APPROVED     PROV NBR/TYPE:                                
 RECIP NAME/ID: LAST               FIRST    I 00000000 SEX: M AGE/LA:  00 00
  LINENAV: 00                                                               -   
 LI COMMENTS/PROCEDURE DESCRIPTION   PROC    MOD1-4           REV  DRUG  DAANES 
 03                                 T1019                                     
    PERSONAL CARE SERVICES, 15 MIN           START/END DT: MMDDYY MMDDYY        
    REQ RATE/UNIT:      0.00            REQ TOT UNITS/AMT:       0000   00000.00
    PROV NBR/NAME: 0000000000  HOME CARE PROVIDER                 SHR/FREQ:   5 
    APP RATE/UNIT:      0.00 SRC: pp   TOT USED UNITS/AMT:     
    STAT CD/DATE: A APPROVED   MMDDYY RSN CD:             RFE:   CTY:   RPT:    
 04                                                                             
    SUPERVISION OF PCA                       START/END DT: MMDDYY MMDDYY         
    REQ RATE/UNIT:      0.00            REQ TOT UNITS/AMT:         00     000.00
    PROV NBR/NAME:  00000000000 HOME CARE PROVIDER               SHR/FREQ:    5 
    APP RATE/UNIT:      0.00 SRC:PP    TOT USED UNITS/AMT:                      
    STAT CD/DATE: A APPROVED   122809 RSN CD:             RFE:   CTY:   RPT:    
 LI EXC ST USER ID  LI EXC ST USER ID  LI EXC ST USER ID  LI EXC ST USER ID     
 01 274  6                                                                      
 274 RECIPIENT IS ELIGIBLE FOR MEDICARE.  YOU NEED TO CHECK WHETHER             
     THESE SERVICES ARE PAID BY MEDICARE.                                       
ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12 
 PAGE  HELP        S/EXT NAVIG SLIST N/EXT PREV  NEXT         OOPS

How to read the ASA3 panel

  1. The LI, COMMENTS/PROCEDURE DESCRIPTION, PROC and MOD1-4 field names are displayed above the data and field names apply to both lines on the page.
  2. The LI field refers to the line number.
  3. The PROC field is for entry of the procedure code (HCPC) assigned to the service being authorized.
    • In the example above procedure code T1019 is Personal Care Services, 15 minutes.
  4. The MOD1-4 fields are for any modifiers that may apply. Modifiers with a procedure code change the service being authorized.
    • In the example above procedure code T1019 with modifier U5 is reduction of PCA services and T1019 with modifier UA is Supervision of PCA.
  5. REV, DRUG and DAANES fields are not used on waiver, AC or Home Care service agreements.
  6. REQ RATE/UNIT field is for entry of requested rate per unit of service.
  7. REQ TOT UNITS field is for entry of total requested units of service.
  8. AMT field is auto calculated and entered by MMIS.
  9. PROV NBR field is for entry of provider's NPI (National Provider Index) number.
  10. PROV NAME field is auto-populated by MMIS based on NPI entered in PROV NBR field.
  11. SHR field is only used with PCA (Personal Care Attendant) or PDN (Private Duty Nurse) services when there is shared care.
  12. FREQ field is only used with PCA services to describe frequency of service.
  13. APP RATE/UNIT (approved rate per unit), SRC (rate source), RFE and CTY fields are populated by MMIS.
  14. RPT field allows line to be copied the same number of times as number entered in this field.
  15. TOT USED UNITS/AMT is populated by MMIS with the total units used and the total amount that has been paid on claims for the line.
  16. STAT CD is for entry of line status code and MMIS enters DATE.
  17. RSN field is for entry of reason codes. Reason codes are entered by worker and sometimes auto-populated by MMIS.

MMIS navigation review on the ASA3 panel

  1. To view additional lines when there is a + or +/- on the screen press F8 to advance and F7 to return.
  2. Enter a two-digit number in the LINENAV field to go directly to that line. LINENAV field will only navigate to completed lines.
  3. In add or change mode press F11 to navigate to the next blank line to enter a new line.
  4. F4 function key is helpful and on the ASA3 panel for looking up additional information.
    • Place cursor on procedure code and press F4 to navigate to the REFERENCE FILE and look up information about that procedure code including valid place of service, rate, provider types that can provide that service and much more.
    • Place cursor on provider NPI number and press F4 to navigate to the PROVIDER APPLICATION FILE.
    • Place cursor on PMI and press F4 to navigate to the RECIPIENT FILE APPLICATION.
    • Place cursor on reason code and press F4 to navigate to view the reason code text that will display on service agreement letters.
  5. F6 exits current location and returns to MMIS panel where F4 function key navigated from.
  6. To exit and save data entered use function key F3. Use F3 key only when completely finished entering data and are ready to finalize document.

The Type B Home Care service agreement also includes screens to enter the MA Health Status Assessment. We will look at those screens next.

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