Form 1142, PACE/SASO Registration Change

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Documents

Effective Date: 12/2014

Instructions

Updated: 12/2014

Purpose

The Program of All-Inclusive Care for the Elderly (PACE) organization staff prepare Form 1142 to notify the Texas Department of Aging and Disability Services (DADS) when a service authorization change is needed for the participant receiving PACE services. Example: A change from Medicaid Only to Dual Eligible.

Procedure

When to Prepare

Form 1142 is prepared by PACE organization staff to notify DADS when a service authorization change is needed.

Transmittal

The PACE organization staff complete Section 1 of Form 1142 and send the form to the DADS regional office for data entry and a copy to the designated PACE consultant. The DADS regional office completes the “DADS 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 1142 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 DADS 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.

Service Authorization Date of Change — Enter the effective date of the change which must be the first day of the month. Check the appropriate box to indicate the service authorization will change to 39 — Dual Eligible (Medicare and Medicaid) or 39A — Medicaid Only.

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 DADS — DADS 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 DADS regional office for data entry and to the designated PACE consultant. — The PACE organization staff send the completed form to the DADS 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.

DADS Regional Office Use Only

Data entered by and Date — DADS 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 — DADS 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 DADS regional office and PACE consultant after corrections are completed.