Medicaid provides for medically necessary health services to eligible recipients in nursing facilities. Prior approval is required.
The purpose of this review is to determine whether the recipient meets or continues to meet the level of care necessary for long-term care placement based on nursing facility criteria. The appropriate level of care — high nursing facility (HNF) or low nursing facility (LNF) — will be determined by Medicaid UR. The initial request on form ISD 379 must be accompanied by a valid physician's or nurse practitioner's order for the Medicaid level of care, the Level I PASRR screen, the PASRR waiver letter, a current history and physical (within six months of the assessment date for a new admission) and the reason for nursing facility placement. A valid level of care order must be signed, dated, and indicate the level of care requested (HNF or LNF). If an abstract is submitted for a resident whose eligibility has not yet been determined, "Medicaid Pending" must be written across the top of the abstract. Upon notification, the facility must call Medicaid UR to advise of the effective date; days will then be applied to the abstract and a copy mailed to the facility.
Continued stay requests
These requests must be received prior to the end of the current certification period. The facility must provide a valid order for the level of care signed by physician or nurse practitioner within 60 days prior to the start date of the continued stay and current signed and dated progress notes.
Change in the level of care
Medicaid UR must also be notified in the event of a change in level of care. A valid, signed level of care must be provided with form ISD 379; if the resident is being readmitted after discharge from a hospital, the hospital discharge summary, and/or admission note must also be included.
Facility readmissions
Nursing facilities are not to submit readmissions to Medicaid Utilization Review unless there is a level of care change. Please refer to the Utilization Review Instructions for Nursing Facilities (Section 8.312.2UR) in the MAD Program Policy Manual.
If there is a change in level of care, a readmit abstract packet must be submitted. Indicate "LOC Change" on the top of a new abstract, and include a valid level of care order signed and dated by the physician, as well as the hospital discharge summary and/or resident's admission note back to the nursing facility. Once approved, days will be issued in accordance with the Utilization Review Instructions.
Back to main Review Types page | Back to main Providers page
