MMIS TYPE B HOME CARE SERVICE AGREEMENT- AHC1, AHC2 and AHC3
The Type B Home Care service agreement contains 3 panels not included on the waiver service agreement. The panels are AHC1, AHC2 and AHC3.
The purpose of the AHC1 and AHC2 screens is to document a MA (Medical Assistance) Health Status Assessment (DHS-3244) in MMIS and allow the completion of a Type B Home Care service agreement.
- For PCA and CSG services MMIS calculates the Home Care Rating (HCR) and total time automatically after the MA Health Status Assessment is entered in the Type B service agreement and worker presses F9 function key to edit the document.
- The Home Care Rating and Total Time fields are located on the AHC1 panel.
- Home Health Agencies and Private Duty Nurse services providers submit service agreement requests through MN-ITS. Information enered in MN-ITS is interfaced into MMIS. MN-ITS is the DHS billing system for Minnesota Health Care Programs (MHCP) claims and other transactions.
The AHC3 screen is used by the assessing nurse to document additional information as needed or requested by DHS. Additional information entered on the AHC3 panel is for documentation and is not displayed on service agreement letters.
Table of MMIS HOME CARE - AHC1 panel
NEXT: AHC2 MMIS HOME CARE - AHC1
AUTHORIZATION NBR: 0000 000 0 000
AGMT TYPE/STAT: B A APPROVED TIME IN: 00:00:00 TIME OUT: 00:00:00
PROV NAME/NBR: PHONE 000 000 0000
LAST FIRST
SPRVSN NURSE NAME: LAST FIRST
ASSESSMENT DATE: MMDDYY BEGIN DATE: MMDDYY END DATE: MMDDYY
RECIP NAME/ID: LAST FIRST C 00000000
DOB(MMDDYYYY): MMDDYYYY AGE: 00 SEX: M LA: 00 WAIVER:
CD CD TIME CD TIME
NURSE VISIT PDN-RN X PC
HOME HEALTH AIDE PDN-LPN X PC SUPERVISION
DIAGNOSIS 1: 000.0 DIAGNOSIS 2: DIAGNOSIS 3:
HOME CARE RATING: S TOTAL TIME: 210
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
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Table of the MMIS HOME CARE - AHC2 panel
NEXT: AHC3 MMIS HOME CARE - AHC2
AUTHORIZATION NBR: 0000 000 0 000
AGMT TYPE/STAT: B A APPROVED PROV NBR/TYPE:
RECIP NAME/ID: LAST FIRST 00000000 SEX: M AGE/LA: 00 00
CD TIME CD TIME CD TIME
ASST/MED: TUBE FEEDING: PRTR THYP:
WOUNDS: RESP ASSIST: CATHETERS:
BOWEL PROG: NEUROLOGICAL: OTHER:
COMMENT: TREAT/MNT:
SEIZURES: COMMENT: LEVEL 1 BEH:
SELF INJURES: HURTS OTHERS: AGGRESSION:
HABITS: RESISTIVE: OFFENSIVE:
LEV3BEH: DRESSING: X GROOMING: X
BATHING: EATING: TRANSFERS: X
MOBILITY: POSITIONING: TOILETING: X
I/SADL: APPL/EQUIP:
SHARED CARE: COMMENT:
FSG: EN: MT: CS: PROV OWN/CTRL: N
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
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Table of MMIS HOME CARE - AHC3 panel
NEXT: ADHS MMIS HOME CARE - AHC3
AUTHORIZATION NBR: 0000 000 0 000
AGMT TYPE/STAT: B A APPROVED PROV NBR/TYPE:
RECIP NAME/ID: LAST FIRST 00000000 SEX: M AGE/LA: 00 00
ADDITIONAL INFORMATION
DECREASE DUE TO LEGISLATIVE RULES APPLIED
00 U/D, 0 U/M QP FLEX (0000, 0000)
REFERRAL RECEIVED MMDDYY
APPROVED-MMDDYY (INT)
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.
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Reminder that the Type B Home Care service agreement has three panels, AHC1, AHC2 and AHC3, that are not included in waiver service agreements.
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