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April 04, 2022, 10:48 EDT

Chapter : Appendix D: Instructions for Completing the Patient Intensity Rating System Review



  1. Read the instructions thoroughly and refer to them when completing the Patient Intensity Rating System Review (PIRSR) form.
  2. Who should complete the form?

This form does not have to be completed by a Registered Nurse (RN). Any staff that the Administrator chooses may complete it. Please have the person who completed the form sign and date it as well. The Administrator of record must also sign and date the form.

  1. For which residents should the form be completed?

The form should be completed only for residents who are currently Medicaid- eligible and have received their Medicaid identification numbers from the local Department of Social Services (DSS) office. A form can be completed on a resident whose eligibility is pending, but do not submit it to the Department of Medical Assistance Services (DMAS) until a MAP-122 form and the Medicaid identification number have been received.

  1. When should the form be completed?
    • When a resident has not been financially eligible for Medicaid for more than 30 days (for state facilities, 60 days); or
    • When a resident has been transferred to or from a Specialized Care Unit (only applies to those nursing facilities, which have a contract to provide Specialized Care).
  2. Where should the form be sent once it is completed?

Please return the completed form by mail to:


Aging & Medical Services Unit Long Term Care Division

Department of Medical Assistance Services 600 East Broad Street, 10th Floor Richmond, Virginia 23219



You may also fax the form to:

Aging & Medical Services Unit

Fax: (804-452-5456)               All Others Fax:  (804-452-5468)


If you have questions, please call:

Provider Call Center Phone #: 1-804-552-8627


Assessment Date: Enter in numerical format the month, day, and year the PIRSR is completed by a RN.

Reason for submission: Check only one reason why the PIRSR is being completed:

    • Admission (resident is Medicaid-eligible or converting to Medicaid)
  1. Identification Information
    1. Resident Name: Print full name (last name first) with middle initial as found on the Medicaid identification card or the DMAS Eligibility Card Replacement Listing. Do not use nicknames.


    1. Birth Date: Enter in numerical format the month, day, and full year of the resident’s date of birth.
    2. Sex: Check the appropriate box for male or female.
    3. Medicaid Number: Do not leave blank. Use the 12-digit number provided on the MAP-122 form, Medicaid card, or the Eligibility Card Replacement Listing. The letters following the number are not needed.


    1. Social Security Number: Do not leave blank. Only use the number specifically designated for the resident and not the spouse’s number.


  1. Summary of Providers (This section is required in order to generate a Notification Letter to providers giving them authorization to bill for services.)


    1. Prior Provider: In order for DMAS staff to determine whether a Nursing Home Pre-admission Screening was required for admission reviews only, these lines must be completed in their entirety for the last TWO most recent providers of care. Addresses are not required, but include a city that will denote the location, or which facility in a chain is submitting the data. An admission date and a discharge date are required. If there is a delay between the discharge date of the prior provider and the admission date of the current provider, a note should be attached explaining the time lapse. If the resident was not in another nursing facility or hospital prior to admission, write “admitted from home or the community.”



    1. Current Provider: The current provider is the facility submitting the form. Complete this line in its entirety, or reimbursement may be delayed. The provider number must be the nine-digit number assigned to the facility by DMAS as of the October 1, 1990 conversion to nursing facility care. The admission date, entered in the numerical format of month, day, and year, should be the date the resident was originally admitted to the facility. If the resident was formally discharged and re-admitted, use the most recent date of admission. However, if the resident leaves the facility but is not formally discharged, use the original admission date and not the date the resident returns. Do not complete the discharge date field unless the resident has been formally discharged (i.e., is discharged home permanently or has expired).
    2. Current Payment Source: Check only one box:
      • Nursing Facility/Medicaid Only
      • Medicare/Medicaid Co-pay (This box should be checked when the resident meets Medicare skilled care criteria and resides in a Medicare- certified bed.)