Long Term Care Resources
DHMH 3871 & 3871B – Forms/Instructions/Transmittals
Chronic Level of Care Requests
- DHMH 3871 - Medical Eligibility Review Form [pdf]
- Ventilator Patient Comorbidity Rating Scale – Chronic [pdf]
- Ventilator Specific Question Form – Chronic [pdf]
Nursing Facility Level of Care Requests:
- DHMH 3871B – Medical Eligibility Review Form [pdf]
- DHMH 3871B - Instructions for completing the 3871B form [pdf]
- DHMH 3871B - Medical Eligibility Review Additional Information Form [pdf]
- Brief Interview for Mental Status (BIMS) - Form & Instructions [pdf]
- DHMH Nursing Home Transmittal No. 213 – Criteria for Level of Care [pdf]
- DHMH Hospital Transmittal No. 215 - Criteria for level of care [pdf]
ADVISORY Level of Care (MER) for Nursing Facility
The Advisory Medical Eligibility Review (MER) is completed for those candidates that are seeking placement into a Long Term Care Nursing Facility. The information submitted is reviewed for medical, cognitive and functional condition. The determination is based solely on the information received; therefore the review determination is non-binding.
Advisory reviews are for those candidates that do not have Maryland Medical Assistance, have not yet applied or are not planning to apply in the next 30 days.
Steps to be taken to have an Advisory Medical Eligibility Review completed:
- Download a copy of the DHMH 3871B – Medical Eligibility Review Form [pdf].
- Please have the candidate’s physician/physician assistant/certified nurse practitioner complete the 4 page form, sign and date.
- The 3871B form and $30.00 (check or money order made payable to Delmarva Foundation) should be sent to Delmarva Foundation.
- Please make sure there is contact information, telephone number and address of the person submitting the information in case there are additional questions we have during the review.
- The 3871B and money should be mailed to:
9240 Centreville Road
Easton, MD 21601
ATTN: MDMA LTC
- Once Delmarva Foundation receives the information, the 3871B will be reviewed and a determination will be made whether the candidate meets the Maryland Medicaid criteria for nursing home services.
- A letter will be mailed to the person submitting the information to inform them of Delmarva Foundation’s decision.
- Once you have received the letter from Delmarva Foundation, please give a copy of the letter to the Nursing Facility that the candidate is seeking placement.
- The letter will indicate a 30-day span. During this span the candidate will need to be admitted into the nursing facility. If the advisory level expires, a new 3871B and another $30 will need to be mailed to Delmarva Foundation.
iEXCHANGE® User Information
- Treatment Update Search Tip Sheet (08/05/11)
This tip sheet includes an overview of the steps for Facilities to find updates and outcomes of requests submitted via iEXCHANGE®.
- Request Tip Sheet - Inpatient (03/11/11)
This tip sheet includes an overview of the steps required for Acute Hospitals, Chronic/ Special Hospitals, and Nursing Facilities to submit an Inpatient Request for DFMC via iEXCHANGE®
- Request Tip Sheet - Other (03/11/11)
This tip sheet includes an overview of the steps required for Facilities to submit Waiver (Outpatient) Requests for DFMC via iEXCHANGE®.
To request hard copies of the DHMH 257 (in triplicate) please write or fax to the attention of Ms. Kimberly Quick. Please include your provider name, provider number and address with your request.
Ms. Kimberly Quick
Department of Health and Mental Hygiene
Office of Eligibility Services
201 West Preston Street, Room L-9
Baltimore MD 21201
Phone # 410-767-6899
Fax # 410-333-5046
Administrative Days Requests:
- DHMH 2129 - Administrative Days in Nursing Facility Report [pdf]
- DHMH Transmittal 233 – Administrative Days in Nursing Facilities [pdf]
- DHMH 1288 – Report of Administrative Days in Chronic Hospitals [pdf]
- DHMH Memo – Requirements for Administrative Days in Chronic Hospitals [pdf]
Other Forms & Tools
To clarify the Bedhold memo with regards to the need for a Level of Care, there are two aspects; Financial and Medical.
For Financial purposes, the Nursing Facilities (NF) will not be reimbursed during the time a resident is out of the facility. The memo does encourage the Nursing Facilities to re-admit previous residents.
For Medical eligibility, the following decision tree applies:
- If the patient has been in the Hospital for 15 days or less and is returning to the Same Nursing Facility – No Level of Care is required
- If the patient has been in the Hospital for 15 days or less and is being discharged to a New Nursing Facility – A Level of Care is required
- A Hospital stay of 16 days or more – A Level of care is required
- If the patient is either being admitted or returning to any Nursing Facility under Medicare as the primary payor – A Level of Care is NOT required
- Temporary ID Number Request Form [pdf]
- DHMH 4345 - Preadmission Screening & Resident Review [pdf]
- DHMH - Maryland Medical Assistance NF Assessment & Reimbursement Handbook [pdf]
Any questions may be addressed to Delmarva's Provider Service Line at 1-866-571-3629.