Effective Date
Instructions
Updated: 12/2014
PURPOSE
The Program of All-Inclusive Care for the Elderly (PACE) organization staff prepare Form 1141 to notify the Texas Health and Human Services Commission (HHSC) when a participant is disenrolling from PACE. Form 1141 is used by HHSC staff to complete data entry into the Service Authorization System Online (SASO), based on the information contained on the form.
PROCEDURE
When to Prepare
Form 1141 is prepared by PACE organization staff to notify HHSC when a participant disenrolls from PACE.
Transmittal
The PACE organization staff complete Section 1 of Form 1141 and send the form to the HHSC regional office for data entry and a copy to the designated PACE consultant. The HHSC regional office completes the “HHSC Regional Office Use Only” section of the form and returns the SASO form to the PACE organization once data entry is completed. The PACE consultant and regional office staff may utilize Section 2 to submit comments to the PACE organization.
Form Retention
Retain Form 1141 for the length of time specified in the program rules.
DETAILED INSTRUCTIONS
PACE Organization Name — Enter the name of the PACE organization.
Contract Number — Enter the contract number of the PACE organization.
Transmittal Date — Enter the date the PACE organization staff send the form to the designated PACE consultant and to the HHSC regional office for data entry.
Participant Name (Last, First) — Enter the last and first name of the participant. Note: To avoid processing delays, the PACE organization staff must resolve issues related to different names on official documentation before submitting the SASO form.
Medicaid Number — Enter the participant’s nine-digit Medicaid number.
Social Security Number — Enter the participant’s nine-digit Social Security number.
Participant Residence Address — Enter the street address, city and state for the participant.
ZIP Code — Enter the participant’s ZIP code.
County — Enter the county where the participant resides.
Disenrollment — Check the appropriate box for Voluntary Disenrollment, Death or Involuntary Disenrollment. Note: Prior approval must be obtained from HHSC state office staff for an involuntary disenrollment.
Disenrollment Date — For all types of disenrollment, enter the disenrollment date. For voluntary and involuntary disenrollments, the disenrollment date must be the last day of the month. For disenrollments due to death, the disenrollment date is the actual date of death.
Reason for Disenrollment — Enter a brief explanation for the reason for disenrollment.
SASO Termination Code — Enter the relevant code for disenrollment from the list of SASO termination codes.
| Code | Reason for Termination |
|---|---|
| 01 | Client leaves the state/county (catchment area) |
| 02 | Death of client |
| 03 | Admitted to institution |
| 04 | Hospital stay exceeds 120 days |
| 05 | Client requests service termination |
| 06 | Client denied Medicaid eligibility |
| 07 | Threatens health/safety |
| 08 | Loses level of care (medical necessity) |
| 09 | Client needs exceed program requirements |
| 10 | Denied due to income |
| 11 | Denied due to resources |
| 12 | Denied due to lack of functional need |
| 13 | Denied due to unmet need (six hour) |
| 14 | No medical need |
| 15 | Abused Emergency Response services |
| 16 | Failure to provide information |
| 17 | Failure to follow service plan |
| 18 | Exceeds cost ceiling |
| 19 | Providers have refused to service client |
| 20 | Fails to pay room and board/co-payment |
| 21 | Refuses to sign service plan (treatment plan) |
| 22 | Refuses to release medical information |
| 23 | Transferred to another service |
| 24 | Denied due to functional score change |
| 25 | Funds not available |
| 26 | Withdrew due to dissatisfaction with quality |
| 27 | Withdrew due to dissatisfaction with quantity |
| 28 | Withdrew preference of own physician (PACE) |
| 29 | Discharged from facility |
| 30 | Level of need/care expired |
| 31 | Elopement |
| 32 | Admitted to hospital |
| 33 | Client transferred to hospice |
| 34 | Client transferred to managed care |
| 35 | Client temporarily in nursing home |
| 36 | Individual’s whereabouts are unknown |
| 37 | Substantial or demonstrated pattern of abuse or |
| 38 | Reckless behavior may result in imminent danger |
| 39 | Other |
Coordination for PACE Disenrollment:To be completed by the PACE organization — PACE organization staff check the appropriate box to indicate if the participant will receive services through:
- STAR+PLUS Waiver, including the date the participant is placed on the interest list;
- Other Community-based Services, including the name of the service and date of enrollment;
- Referral to HHSC Regional Office, including the date of referral; or
- No other services will be received.
Comments from PACE Organization — PACE organization staff may enter additional information relevant for data entry.
Name, Title and Phone Number of PACE Staff Completing Form — Enter the name, title and phone number for PACE organization staff completing the form.
Comments from HHSC — HHSC PACE consultant and regional office staff may enter comments for PACE organization staff, which may include requests for additional information for data entry.
Submit completed form to the HHSC regional office for data entry and to the designated PACE consultant. — The PACE organization staff send the completed form to the HHSC regional office for data entry and to the designated PACE consultant once the SASO form has been checked for accuracy by the PACE organization staff.
HHSC Regional Office Use Only
Data entered by and Date — HHSC staff enter his/her name and the date the information is entered into SASO, or the date the form is returned to the PACE organization without data entry (due to errors).
Form returned to PACE organization without data entry and Date — HHSC staff check the box and enter the date the SASO form is returned to the PACE organization because of errors. The PACE organization staff must submit a new SASO form to the HHSC regional office and PACE consultant after corrections are completed.