1. A. The LTSS screening entity shall complete and submit the following forms to DMAS electronically via eMLS:

   1. 1. DMAS-95 - MI/ID/RC (Supplemental Level I Screening for Mental Illness, Intellectual Disability, or Related Conditions Form and follow-up information), as appropriate;
   2. 2. DMAS-96 (Medicaid-Funded Long-Term Services and Supports Authorization Form);
   3. 3. DMAS-97 (Individual Choice - Home and Community-Based or Institutional Care Form), as applicable;
   4. 4. UAI (Uniform Assessment Instrument);
   5. 5. DMAS-108 ( Private Duty Nursing Adult form), as appropriate; and
   6. 6. DMAS-109 ( Private Duty Nursing Pediatric form), as appropriate.
2. B. For LTSS screenings performed in the community, the LTSS screening entity shall submit to DMAS via eMLS each applicable screening form listed in subsection A of this section within 30 days of the individual's request date for screening.
3. C. For LTSS screenings performed in a hospital, the LTSS screening hospital team shall submit to DMAS via eMLS each applicable screening form listed in subsection A of this section, which shall be completed prior to the individual's discharge to LTSS.
4. D. For LTSS screenings performed in a skilled or rehabilitation NF setting, the NF LTSS screening team shall submit to DMAS via eMLS each applicable screening form listed in subsection A of this section, which shall be completed prior to the individual's level of care change or enrollment in LTSS from skilled nursing or rehabilitation services.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 34, Issue 24, eff. August 22, 2018; amended, Virginia Register Volume 36, Issue 7, eff. December 25, 2019; Volume 41, Issue 1, eff. October 10, 2024.