CMS Pub. 100-11, ch. 8, § 20.10

In addition to the semiannual and annual reassessments described above, two situations

should trigger participant reassessment. First, if a participant experiences a significant

change in health or psychosocial status, the eight IDT members (primary care physician,

registered nurse, master’s level social worker, physical therapist, occupational therapist,

recreational therapist or activity coordinator, dietitian, and home care coordinator) must

conduct an in-person reassessment. Secondly, when a participant or his or her designated

representative believes that the participant needs to initiate, eliminate, or continue a

particular service, the IDT members will determine the pertinent practitioners to conduct

the in-person reassessment. The PACE organization must have explicit procedures for

timely resolution of requests by a participant or his or her designated representative to

initiate, eliminate, or continue a particular service. The IDT must notify the participant or

designated representative of its decision to approve or deny the request from the

participant or designated representative as expeditiously as the participant’s condition

requires, but no later than 72 hours after the date the IDT receives the request for

reassessment. However, the IDT may extend the 72-hour timeframe for notifying the

participant or designated representative of its decision to approve or deny the request by

no more than 5 additional days if the participant or designated representative requests the

extension or the IDT documents its need for additional information and how the delay is

in the interest of the participant. The PACE organization must explain any denial of a

request to the participant or designated representative orally and in writing. The PACE

organization must provide the specific reasons for the denial in understandable language.

The PACE organization is responsible for: (1) informing the participant or designated

representative of his or her right to appeal the decision; (2) describing both the standard

and expedited appeals processes, including the right to, and conditions for, obtaining

expedited consideration of an appeal of a denial of services; and (3) describing the right

to, and conditions for, continuation of appealed services through the period of an appeal.

If the IDT fails to provide the participant with timely notice of the resolution of the

request or does not furnish the services required by the revised plan of care, this failure

constitutes an adverse decision, and the participant’s request must be automatically

processed by the PACE organization as an appeal in accordance with 42 CFR § 460.122.

Intervals Performed Minimum Disciplines Involved

Unscheduled • In-person

• Change in participant status

(health or psychosocial)

• At the request of the

participant or designated

representative

• PCP, RN, SW, Recreational

Therapist/Activity Coordinator,

PT, OT, Dietitian, and/or

Homecare Coordinator as needed

• Other team members actively

involved in development or

implementation of POC

[42 CFR § 460.104(d)]