DA-124 Assessment Form Reminders

DA-124 forms are required for Medicaid vendor reimbursement.  The Central Office Medical Review Unit (COMRU) would like to remind nursing facilities and hospitals to review the DA-124 forms for errors before submitting for processing.  To avoid the return of your DA-124 forms and cause a delay in your Medicaid reimbursement processing, review the following key areas:

  • Utilize the most current version of these forms: DA-124A/B form # MO 580-2460 (9-07) and DA-124C form # MO 580-2462 (9-07) available on the website at: http://health.mo.gov/seniors/nursinghomes/pasrr.php.
  • Submit the DA-124A/B and the DA-124C forms together for processing.
  • Include the client’s education level and prior occupation.
  • If the client is disabled, include the date and diagnosis.
  • Review the instructions on the back of the DA-124C form regarding MR related conditions.
  • Include the dosage and frequency of all medications – you may attach a legible copy of the Medication Administration Record.
  • If using a continuance sheet, use a full sheet of paper and include the client’s name.
  • Assessed needs – be specific when describing the client’s requirements and include the amount of staff assistance.
  • Sign and date both DA-124 forms, and include your telephone number, fax number and e-mail address.
  • Review and follow the instructions on the DA-124C form, Section B:  Screening Criteria for Mental Illness.  If the client has, or had a Mental Illness diagnosis, it must appear on Section B, #2.  Review the instructions for Question #3.
  • Include the physician’s license and discipline number.  (If not available:  print the physician’s name below the signature line). 

If you have any questions, please contact the Section for Long-Term Care Regulation, COMRU at 573-526-8609 or E-Mail:  COMRU@health.mo.gov.