To fill out Pennsylvania Form MA 103, the Long Term Care Admission and Discharge Transmittal, a facility administrator or the resident’s attending physician works through six sections covering resident identification, the authorized service, discharge planning, any recommended change in care level, and transfer or discharge details, then signs and dates the form. The two-part snapset splits after signing: the original stays in the resident’s clinical record, and the copy goes to the County Assistance Office within three days.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal Residents and family members do not file this form; it is a facility document.
Who Completes the MA 103 and When
The facility prepares an MA 103 whenever one of four things happens to a Medical Assistance applicant or recipient: admission to the facility, conversion from private pay to Medical Assistance, discharge or transfer when the resident no longer needs the level of care the facility provides, or death.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal Each event gets its own form. The sections you complete depend on the event: an admission relies on resident and provider identification, while a discharge adds planning data and a discharge code.
Section-by-Section Walkthrough
Incomplete entries in any section that applies to your event will cause the CAO to return the form. Work through the sections in order.
Section I: Resident Data
Print the resident’s last name, first name, and middle initial in field 1. Field 2 is the Access Number, the ten-digit number on the resident’s MA ACCESS card; copy it exactly as shown. Field 3 is the Social Security number. Field 4 is the date of birth in six-digit format, with a leading zero for any single-digit month or day. Field 5 is sex, marked M or F. Field 6 is the county where the facility is located, not the resident’s prior home county.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal
Section II: Provider Data
Fields 7a through 7e identify the service the Department currently authorizes for the resident: nursing facility services, ICF/ORC, inpatient psychiatric, ICF/MR, or Other. Mark whichever box matches the authorization shown on the resident’s PA 162 Notice. If none of the listed categories fit, mark Other and describe the service. Field 8 is the facility admission date. Field 9 applies only when the Department approved a limited stay; mark it and note the authorized length.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal
Field 10 is the facility name as it appears on your MA Provider Notice. Do not shorten it or substitute a doing-business-as name. Field 11 is the nine-digit Service Provider ID followed by the four-digit Service Location Code. Field 12 is the attending physician’s full name with degree. Field 13 is that physician’s Medical Assistance identification number, or the physician’s license number if they are not enrolled in the MA Program.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal
Section III: Discharge Planning Data
Every resident must have an individualized discharge plan kept current with their condition. Field 14 is the date the plan was most recently reviewed or updated. Field 15 asks whether the plan contains six required elements: current diagnosis information, a description of prior treatments, rehabilitation potential, the physician’s advice on immediate care needs, pertinent social information, and information on available community resources for referral. Mark yes or no for each. Any no answer requires an explanation in the comments section describing the deficiency and the corrective steps being taken.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal
Section IV: Change of Care Recommendation
Complete this section only when the resident’s condition warrants a different level of care. Field 16 lists the same service categories as Section II. Check the one that matches the recommended new level and write a brief clinical summary explaining why the change is warranted.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal
Section V: Transfer or Discharge
Field 17 takes a two-digit code. The form distinguishes a discharge, where the resident has no intent to return, from a transfer, where the resident does intend to return. The codes are:
- 01: Routine discharge
- 02: Discharge against medical advice
- 03: Expired, no autopsy
- 04: Expired, autopsy
- 05: Transfer or discharge to hospital
- 06: Transfer or discharge to nursing facility
- 07: Transfer or discharge to rehabilitation facility
- 08: Transfer or discharge to psychiatric facility
- 09: Discharge to boarding home
- 11: Discharge to hospital home care
- 12: Other (specify)
Codes 05 through 12 require a written explanation. Fields 18 and 19 document whether a 30-day notice of discharge was sent to the resident and the date it was sent. When reporting a discharge, attach a copy of that 30-day notice to the MA 103. The original 30-day notice and the original MA 103 both stay in the resident’s clinical record.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal
Section VI: Administrator Signature
The facility administrator or an authorized designee signs field 20 and dates field 21. The signature certifies that everything on the form accurately describes the resident’s condition and needs at the time of the event being reported.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal
Submitting the Form
After signing, separate the two parts of the snapset. The copy labeled Resident’s Clinical Record is the original and stays in the facility’s file. The copy labeled County Assistance Office (CAO) goes to the CAO that serves the facility’s county, and you have three days from the completion date to send it.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal On a discharge, attach a copy of the 30-day notice to the CAO copy as well.
Common Reasons Forms Get Returned
A few errors account for most rejected forms. The Access Number is missing or mis-copied. The facility name does not match the MA Provider Notice. A discharge code of 05 through 12 is entered without the required written explanation. Either the nine-digit Service Provider ID or the four-digit Service Location Code is left off, which creates a mismatch in the state’s records. Checking these fields before you separate the snapset is faster than reworking a returned form.
Where to Get a Blank MA 103
The form is available as a PDF download from the Pennsylvania Department of Human Services website.1Commonwealth of Pennsylvania. Long Term Care Admission and Discharge Transmittal It also appears in the Long-Term Care Handbook forms index and the Medical Assistance Handbook forms listing maintained by the Department.2Pennsylvania Department of Human Services. Long-Term Care Handbook Forms If you need physical snapset copies rather than printed PDFs, contact your County Assistance Office directly to request a supply.
Not the Same as the Personal Care Home Supplement Application
The MA 103 is a transmittal used by nursing facilities and similar long-term care settings to report admissions, care-level changes, discharges, and deaths. It is not the application for the Personal Care Home Supplement. That supplement uses Form PA 761 for personal care homes and Form PA 1-D for domiciliary care homes.3Pennsylvania Department of Human Services. Medical Assistance Eligibility Handbook – 391.3 Application for the Supplement If you are trying to help a resident apply for the supplement rather than report a long-term care event, the MA 103 is not the form you need.