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Click ‘Get Form’ to open the PAE form in the editor.
Begin with Section I: General Information. Fill in the provider's name, address, and contact details. Ensure all fields are completed accurately.
In the Reason for Pre-Admission Evaluation section, select the appropriate reason for evaluation by checking the relevant box.
Proceed to Section II: Psychological Evaluation. Enter the level of mental retardation and IQ test score if applicable. Attach any required psychological examination documents.
Move on to Section III: Assessment of Capabilities and Needs. For each capability (bathing, communication, etc.), choose the best answer that reflects the recipient's abilities.
Complete Sections IV and V with medical information and plan of care details as necessary, ensuring all medications and services requested are listed clearly.
Finally, have a qualified professional sign in Section VI to certify that all information is accurate before submitting your completed form.
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The Maximum possible Total Nursing Facility Level of Care acuity score (total NF LOC acuity score) is 26. This can be expressed as: Total NF LOC acuity score = Acuity score for Activities of Daily Living (ADL) or related deficiencies + Acuity score for skilled and/or rehabilitative services.
Is Tennessee Medicaid the same as TennCare?
TennCare is the state of Tennessees Medicaid program.
What is a PAE medical?
What is a prostatic artery embolization? Prostatic artery embolization (PAE) is a minimally invasive treatment that helps improve lower urinary tract symptoms caused by benign prostatic hyperplasia (BPH). BPH is a noncancerous of the prostate gland and is the most common benign tumor found in men.
What is the maximum income to qualify for TennCare?
Age 0 up to 19 (211% FPL) Household SizeYearly Income LimitMonthly Income Limit 1 $33,022 $2,752 2 $44,627 $3,719 3 $56,232 $4,686 4 $67,837 $5,654
What type of insurance is TennCare Select in Tennessee?
The state also operates TennCare Select, a Prepaid Inpatient Health Plan (PIHP), for children who are in foster care, receive Supplemental Security Income (SSI), or receive care in particular institutional settings.
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Pre-Admission Evaluation (PAE) Long Term Care Tool-001
Mar 20, 2012 Completion of all elements does not guarantee Long Term Care approval; the applicant must satisfy medical and financial eligibility requirements
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