Nursing Facility Level of - PowerPoint Presentation

Slide1

Nursing Facility Level of

Care

An Overview

Slide2

Training Objectives

NF Documentation and Eligibility

NFLOC Factors

LOC Review & Length of Stay Determination

Transfer / Reintegration

Reconsideration / Appeals / Fair Hearings

Role of Care Coordinators

Scenarios & FAQs

Appedix

Slide3

Documentation

Requirement

Nursing Facility Level of Care

Slide4

NFLOC

Documentation Requirements

All requests must include the Minimum Data Set (MDS) and the MDS must be current for the time frame requested;

A valid physician’s order for either High Nursing Facility (HNF) or Low Nursing Facility (LNF) level of care for Nursing Home Residents

.

Initial

Request

(Documents must be completed and submitted within 30 calendar days of admission)

MDS

A Valid Physician Order dated within six (6) months of documentation submission date

PASRR Level

1screen pass; if failed a PASRR Level 1, then an approved PASRR Level II

History and Physical (H & P) examination completed within six(6) months of the documentation submission

date

Continuation

Stay Request

MDS

Physician

Order dated within twelve (12) months of documentation submission date

Physician Progress Notes, signed and dated within 90 days of the document submission

date

H & P examination completed within twelve (12)

months of documentation submission date

Slide5

Physician Order Content Requirements

A valid physician order for NFLOC request must have the following elements:

Signed by a physician, certified nurse

practitioner, physician assistant or

c

linical

n

urse

s

pecialist ;

OR

Signed by the RN or LPN who took the verbal or telephone order indicating the name of the provider who provided the LOC order (The R.N. or L.P.N. must clearly indicate that the order is a telephone or verbal order with the name of the provider who gave the LOC order

); telephonic order does not need MD signature at time of submission

Date of the order; AND

LOC indication –either HNF or

LNF

Slide6

Continuation Stay Request

When requesting HNF, in addition

to requirements for continued stay (slide 4),

NF must send documentation supporting the

daily

skilled needs of the resident for the timeframe requested.

If nursing facility (NF) is treating a wound/s, include any and all wound care documentation including wound measurements, location of wound, and treatments ordered that applies  for the time period you are requesting.

If NF is providing therapies (PT, OT, etc.), include therapy evaluations, therapy notes, grids and therapy treatment plan for  the time period you are requesting.

If NF is providing other daily skilled services such as cancer treatments, respiratory treatment or other skilled treatment, submit supporting documentation reflecting the treatment provided.

Include the interdisciplinary treatment plan with the goals, objectives, interventions and progress towards goals.

Slide7

Readmission

The following procedure will be followed when a resident spends more than 3 midnights outside of the NF:

The NF has to submit a re-admit

NF LOC

request within thirty (30) calendar days for HNF determination with the following documentation:

Valid order for

HNF

(defined in slide 5)

The resident’s hospital discharge summary and/or resident’s admission note back to the NF

If

resident is readmitted for LNF LOC certification

, the NF

needs

to notify the MCO of the

readmission via fax using the Communication Form.

If resident has

less than thirty (30) days left on the

NF LOC

certification, the NF should submit a

NF LOC

continued stay request.

Slide8

Discharge Status Eligibility

Discharge Status occurs when a resident no longer meets HNF or LNF level of care, but there is no option for community placement of the resident at that time. Discharge Status does not mean the resident is being discharged from the facility.

Discharge Status is considered when residents may be at risk for failure to thrive outside the nursing facility and discharging the resident places the resident’s health at risk.

Slide9

Discharge Status Documentation Requirements

A valid LOC order

Physician orders are valid for 60 days from date of receipt;

ALL packets must include the MDS.

Documentation must be current for time frame requested;

Submission of a Continued Stay request for a resident in Discharge Status must acknowledge the resident’s Discharge Status and document the facility’s ongoing attempts, in conjunction with Care Coordinator’s effort, to find and develop appropriate community placement options for the resident; and

The facility should document why the resident must remain in the nursing home until the resident can be safely discharged to the community.

Slide10

Nursing Facility (NF) Eligibility

NF General Eligibility (also Low NF eligibility)

Member's

functional level is such that two or more Activities of Daily Living (ADLs) cannot be accomplished without consistent, ongoing, daily assistance in some or all of the following levels of service;

skilled

, intermediate and/or assistance level. Functional limitations of the individual must be secondary to a condition for which general treatment plan oversight by a physician is medically necessary –New Mexico Administrative Code 8.312.2 NMAC.

Slide11

High Nursing Facility (HNF) Eligibility

The resident’s functional level must first meet the general eligibility requirements for LNF.

In

addition, the recipient meets a minimum of 2 High NF requirements in 2 separate categories (The exception to this is rehabilitative therapy. Therapies in excess of 300 minutes per week shall be considered as meeting the 2 HNF requirements in 2 separate categories, thus meeting HNF criteria).

Determination

is based on detailed documentation in interdisciplinary progress notes and care plans.

Slide12

HNF Factors

Nursing Facility Level of Care

Slide13

Factors for HNF: Oxygen

OXYGEN

Resident

is demonstrating unstable and changing oxygen needs which require

specific

direct skilled monitoring and/or intervention on a daily basis that

is documented

in interdisciplinary progress notes and care plans to maintain

adequate

oxygenation and to assess for respiratory depression. Evidence of a

re-established

baseline would

not be evidence

of significant change in oxygen

therapy

over 30 days.

It

is medically necessary for the resident to receive respiratory therapy at

least once

per day such that in the absence of such therapy there is a significant

risk of

pulmonary compromise due to known and predictable complications of

a physician-diagnosed

condition. The necessary therapy cannot

be self-administered

by the resident. This factor includes tracheostomy suctioning.

The

resident is ventilator dependent, but otherwise medically stable per

documentation

provided and the facility provides chronic ventilator

management capability

.

Slide14

Factors for HNF: Oxygen

B. Not

Consistent with

HNF

Resident

requires supplemental oxygen which can be self-administered. The oxygen needs are stable. The recipient does not require daily skilled observation. Resident requires intermittent respiratory therapy that may be administered by family or self-administered in a non-institutional setting.

The

resident is ventilator dependent and has medical needs which cannot safely be met at a nursing facility

.

Slide15

Factors for HNF: Orientation/Behavior

A

. Orientation/Behavior:

Demonstrates

behavior on an ongoing and regular basis which threatens patient or other residents’ safety and requires daily direct clinical skilled interventions which are documented in interdisciplinary progress notes and care plan. (Identify the presence of certain behaviors that may reflect the level of an individual’s emotional functioning and need for intervention. Behaviors should be assessed based on the documentation of interventions within the past 30 days for HNF. Documentation should include frequency, type of behavior, and if there has been or will be a request for Behavioral Health Services.)

Requires a detailed care plan that documents a coordinated and consistent approach that occurs on a daily basis to either prevent or terminate behavior as documented in interdisciplinary progress notes and care plan.

Slide16

Factors for HNF: Orientation/Behavior

B. Not Consistent with HNF

Does

not have a cognitive impairment, but is trying to leave

Paces

due to anxiety, nervousness or boredom

Wanders

but does not require intervention

Uses

profanity to express

anger

Behavior is stable and does not require changes in care plan

Slide17

Factors for HNF: Medication Administration

A. Initiation

(first 30 days) or adjustment of medications (7 days after adjustment) in the following categories

:

Anti-asthmatics/COPD

: only during a respiratory exacerbation

Anti-

infectives

: only when given IV

Anti-

hypertensives

: only for med adjustments for systolic BP<=90 or >180/120

Analgesics

: only when given parenteral

Antiarrhythmics

Anti-diabetic

agents: only following hypoglycemic reactions requiring

glucagon or

IV dextrose

Antipsychotics

- daily monitoring by skilled staff for potential adverse reactions

and

daily documentation of changes in problematic behavior

.

Anticonvulsants only when given parenteral

AND

Where at least every shift direct skilled monitoring of vital signs (respiratory rate, pulse, Oxygen saturation, blood pressure, temperature) and objective signs of pain or other distress are necessary to ensure appropriate therapeutic effect of the medication as well as to detect signs of complications due to the medication that is documented in interdisciplinary progress notes and care plan

.

Slide18

Factors for HNF: Medication Administration

B.

Not Consistent with

HNF

Resident

can administer own oral medications if given assistance in scheduling and assisted dispensing units. The resident can administer own subcutaneous insulin in pre-filled syringes, can administer own subcutaneous or intramuscular medications, and is cognitively capable of reporting any adverse reactions to medications

. Medication dosing is stable.

Slide19

Factors for HNF: Rehabilitative Therapy

A.

Rehabilitative Therapy

It is medically necessary that the resident receive one or more of the following documented therapies on a weekly basis: Speech, physical, and/or occupational therapy. Therapy must be directed toward significant treatable functional limitations which affect ADLs. Therapy must be individualized, goal oriented, and in accordance with specific treatment plan goals in order to maximize recovery. Goals, expectation for improvement, and duration of therapy are medically reasonable and are documented in interdisciplinary progress notes and care plan. Therapy minutes should be documented on the Therapy Administration Record.

In the aggregate, such therapy must occur no less than 150 minutes per week.

Therapies at least 300 minutes per week shall be considered as meeting the 2 HNF requirements in 2 separate

categories

thus meeting HNF criteria

.

Slide20

Factors for HNF: Rehabilitative Therapy

B.

Not consistent with

HNF

The

resident

requires maintenance speech, physical, and/or occupational therapy

performed

on an outpatient basis. Transportation needs are not considered, or the

resident

requires maintenance speech, physical, and/or occupational therapy which can be performed independently or with home-based assistance.

Slide21

Factors for HNF: Rehabilitative Therapy

FOR DUAL Members

1 – Cannot be receiving skilled Part A benefits concurrently. MCO responsible for 20% co-pay of Part A services for days 21-100.

2 – Cannot count Rehabilitative Therapy if eligible for those services through Medicare Part B services

3 - To count rehabilitative service’s time, SNF will need to submit denial (COB) from Medicare for payment for the applicable Part A and Part B services:

a – if Medicare denial is for “not a covered benefit” (length or amount over benefit limit), MCO can review for medical necessity

b – if Medicare denial is for “lack of medical necessity”, then MCO will deny also.

Slide22

Factors for HNF: Skilled Nursing

A. Skilled Nursing

Resident has a new

ostomy

(first 30 days), and there is documentation in the interdisciplinary progress notes and care plan that the resident requires active teaching, and requires direct skilled nursing monitoring and intervention of the

ostomy

.

Slide23

Factors for HNF: Skilled Nursing Continued

Wound

Care

One or more documented stage III or IV decubitus ulcers requiring direct skilled nursing intervention and daily monitoring that is documented in inter-disciplinary progress notes and care plan which includes location, class/stage, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection.

OR

Documented skilled nursing intervention for two or more Stage II decubitus ulcers at separate anatomic sites. Interventions are documented in the interdisciplinary progress notes and care plan no less than every 7 days, which include

location, class/stage

, size, base tissues, exudates, odor, edge/perimeter, pain and an evaluation for infection.

OR

Requires documented daily or more frequent sterile dressing changes (and/or irrigation) for significant, unstable lesions that require frequent nursing observation such as poorly healing, or infected wounds. The resident must be unable to accomplish wound care

.

Slide24

Factors for HNF: Skilled Nursing Continued

B

. Not Consistent with

HNF

Resident receives services outside of the NF that are billed separately, i.e., dialysis, therapies,

transfusions, wound care

at a wound care clinic, etc. or has an indwelling Foley catheter, suprapubic tube, or drain

.

Slide25

Factors for HNF: Other Clinical Factors

A

. Other Clinical Factors

The resident is comatose, in a persistent vegetative state, or is otherwise totally bed bound and totally dependent for all ADLs related to a documented medical condition requiring direct skilled intervention (not monitoring) by a licensed nurse or licensed therapist to prevent or treat specific, identifiable medical conditions which pose a risk to health. The resident’s ability to communicate needs, report symptoms, and participate in care is severely limited and is documented in the interdisciplinary progress notes and care plan

.

Slide26

Factors for HNF: Other Clinical Factors Continued

Feeding:

Resident receives medically necessary parenteral nutrition (PN) solutions via non-permanent or permanent central venous catheter (Hickman,

Groshong

,

Broviac

,

etc

.),

via

peripherally inserted central catheter (PICC),

or

via peripheral access sites.

Resident receives some or all nutrition through a nasoenteric feeding tube (i.e.,

a

tube placed through the nose) AND it is documented that one or more of the permissive conditions for nasoenteric feeding at the Low NF level are

not

met which include all of the following: the tube feeding is uncomplicated, the resident is alert with an intact gag reflex and the resident is able to be fed either upright in a chair or with a bed raised to at least 30 degrees.

Resident receives enteral nutrition via gastrostomy, jejunostomy, or other permanent tube feeding methods

.

Slide27

Factors for HNF: Other Clinical Factors Continued

Mobility/Transfer

The resident is bed bound, unable to independently transfer, and has a clinical condition(s) such that the transfer itself is not routine, is reasonably viewed as posing unusual risks, and there is documentation in interdisciplinary progress notes and care plan that demonstrate that each transfer must be and is monitored by a licensed nurse to assure no clinical complications of the transfer have occurred.

Slide28

Not Appropriate for NF care:

The resident’s needs are too complex or inappropriate for NF, such that:

The resident requires acute level of care for adequate diagnosis, monitoring, and treatment or requires inpatient based acute rehabilitation services.

The resident is completing the terminal portion of an acute stay and the skilled services are only being used to complete the acute therapy. NF care is covered as a post acute benefit and does not need a NFLOC determination

Residents

who do not meet NF LOC

criteria.

The resident requires services on an intermittent basis and has a functional level which does not require daily services at the skilled, professional, or assistance level in order to accomplish ADLs.

The resident requires homemaker services to accomplish one or more ADLs, but is

functional

in accomplishing ADLs 4 or more days of the week

Slide29

Requests for Information (RFI)

The Centennial Care MCO will review all documents provided

by

the provider. If

any

of the required documents are not included or there are incomplete documents with the request for LNF or HNF,

the

Centennial Care MCO will return the packet to the provider and the LOC determination will be suspended until the provider responds.

(

Refer to slide 5 for Documentation Requirements

)

The provider has 14 business days to submit the response to the MCO RFI. Should the provider fail to provide the response to RFI within 14 business days, the MCO will issue a technical denial of the request.

Slide30

Change From Medicaid Pending to Medicaid Eligible

Centennial Care MCO will be selected by Medicaid Applicant prior to determination of Medicaid Eligibility

When

the resident’s Medicaid eligibility is approved per the ISD office, the Nursing Facility (NF) is responsible for

notifying

the Centennial Care

MCO of

the effective date information.

The Centennial Care MCO will confirm Medicaid eligibility by reviewing the daily enrollment data.

The Centennial Care MCO will ensure the complete and current documentation for the period requested is on file, certify timeframes associated with approvals, and fax the approval on the authorization to the

nursing facility.

If there is no current NF LOC certification, the Centennial Care MCO will request the submission of documentations

.

Slide31

Level of care reviews & length of stay determinations

Nursing Facility Level of Care

Slide32

Level of Care Reviews

Approving NF Level of Care (LOC)

If the NF resident meets the NF LOC requested, the Centennial Care MCO will fax an approval authorization for the LOC requested to the provider. The authorization will indicate an approved LOC, HNF or LNF, and the approved Level of Care date span.

If the resident is pending Medicaid eligibility, the authorization number will not be placed on the authorization.

An authorization number will be provided once the Member is financially eligible

.

Slide33

Level of Care Reviews

Denying NF Level of Care

If the History and Physical (H & P), Minimum Data Set (MDS), and any additional information provided does not indicate the NF resident meets NF

LOC, the information will sent to the MCO Medical Director for review. If the Medical Director confirms that the member does not meet NF LOC, the resident

and facility will receive a LOC denial letter. The denial letter will detail the reason for denial with specific regulation information and reconsideration and

appeal

right information.

Slide34

Modification of HNF LOC Requests

The Centennial Care MCO is authorized to issue modified/reduced NF LOC approvals for HNF LOC requests that clearly do not meet HNF criteria, but do meet Low NF criteria.

A formal Request for Information (RFI) to the provider to justify the HNF request is not required when reviewing and processing HNF requests that clearly meet LNF criteria.

A new LOC order specifying LNF LOC is not required on HNF to LNF modified LOC approvals.

LNF approval will be indicated on the authorization and will be faxed to the nursing facility.

A letter is sent to the resident for notification of the reduced/modified LOC approval. A copy of the resident’s letter is sent to the nursing facility

.

Slide35

Workflow

Slide36

Length of Stay Determinations

Initial LNF LOC cannot exceed 90 days , however, a shorter length of stay can be assigned based on the needs of the resident - 8.312.2-UR A, 3 (b) NMAC.

Continuing

LNF LOC cannot exceed 365 days based on the medical needs and stability of the resident - 8.312.2.2-UR B, 2, b (ii) NMAC.

Initial

HNF LOC cannot exceed 30 days, however, a shorter length of stay can be assigned based on the needs of the resident - 8.312.2-UR 2 A, 3 (a) NMAC.

Continuing

HNF LOC cannot exceed 90 days based on the medical needs and stability of the resident - 8.312.2.2- UR B, 2, b (i) NMAC

.

Slide37

Length of Stay Determinations

Discharge Status

Initial

Discharge Status is authorized at LNF for a maximum of 90 days, based upon

a

Medical Director’s

determination. 8.312.2 I (1) NMAC

Continued Stay Discharge Status is authorized at LNF for not less than 180 days, and up to 365 days. 8.312. I (2) NMAC

Slide38

Transfer / reintegration / Reconsideration

Nursing Facility Level of Care

Slide39

Transfer from one facility to another

The nursing facility must notify the Centennial Care MCO when a transfer is to occur from one nursing facility to another. The receiving nursing facility will provide the Centennial Care MCO with the date of the transfer.

If there are more than thirty(30) days on the resident’s current Level of Care, The Centennial Care MCO will send an authorization with the days remaining on the current Level of Care.

If there are less than thirty (30) days remaining on the resident’s current Level of Care, the receiving NF will be requested to send a Continued Stay request with all other required documents for Continued Stay. The days remaining on the current Level of Care will be added to the Continued Stay. The request should indicate that a transfer has occurred

.

Slide40

Community Reintegration

For eligible residents who choose to transition to the community, the care coordinator shall facilitate the development of a transition plan, which shall address the members:

Physical health needs;

Behavioral health needs

Selection of providers in the community;

Housing needs

Financial needs;

Interpersonal skills; and

Safety

For residents who are interested in transition to the community with the Community Benefit

but do

not have full Medicaid eligibility or who are not otherwise Medicaid eligible

may

contact the State Aging and Disability Resource Center (ADRC) at (800) 432-2080 and request a waiver allocation.

The resident will receive a letter from the ADRC with instructions on next steps to complete financial and medical eligibility. When the resident is allocated, the Centennial Care MCO will complete the medical eligibility

assessment, determine

NF LOC

eligibility, and

determine if the member has a full Medicaid category of eligibility. Medical and financial eligibility must be completed within 90 calendar days from the allocation date unless an extension is granted.

A resident must have a 90 day nursing facility stay before an allocation will be given.

Slide41

NFLOC Denials

Technical Denial – there are no appeal rights with a Technical Denial

Medical Denial

Reconsiderations

Slide42

Reconsiderations

The Nursing Facility reconsideration request must be received by the Centennial Care MCO within 30 calendar days from the date of the denial.

The request must have the following information: reference to the challenged decision or action, basis for the challenge, copies of any document(s) pertinent to the challenged decision or action, copies of claim form(s) if the challenge involves a claim for payment which is denied due to a utilization review decision, and statement that a reconsideration of the decision is requested.

The reconsideration process is indicated in the Medical Assistance Program Policy Manual 8.350.2 NMAC

.

Slide43

Appeals

Members must file appeal and complete the appeal process with MCO prior to requesting a State Fair Hearing.

Members must file an appeal verbally or in writing within

30

days of the date of the Notice of Action (NOA) letter

Verbal appeals can be filed through MCO Customer Service

A verbal appeal must be followed within 13 calendar days by a written appeal,

signed

by the member.

Failure to file the written appeal within 13 calendar days constitutes a withdrawal.

The MCO has 30 days from the receipt of the appeal to resolve it.

Per NM Regulations,

if

a provider files an appeal on behalf of a member,

the

member must provide written consent to MCO Appeals Department to begin the process.

Slide44

Fair Hearing

Fair hearings are administered through the HSD Fair Hearings Bureau.

The resident has

90

days to request a Fair

Hearing after the final decision of the appeal.

The resident may utilize the Fair Hearing process after the reconsideration

and appeal process

has been

exhausted

The resident has 13 calendar days from date of denial letter to notify the State of the request for continuation of benefits

.

Slide45

Role of Care Coordinator in Centennial Care

Assessment of Members for Re-integration into the community

Ability to review the resident’s chart and visit with the resident on an “as needed” basis

Participation in Care Planning Meeting of all MCO residents

Slide46

Scenarios

Nursing Facility Level of Care

Slide47

Scenario 1

LNF vs. HNF?

66 year old resident who has been a resident for 3 years

Diagnosis of Diabetes Mellitus II, and Osteoarthritis

Alert and oriented x 3

Receiving routine, unchanging dose of subcutaneous insulin twice a day

Needs one person assist with all ADLs, but does not require skilled attendance and method of such mobility is not highly specialized mandating skilled monitoring and/or intervention

Developed a stage II ulcer on the

coccyx

Slide48

Scenario 1 - Results

Resident does not meet HNF criteria.

Resident does not need skilled attendance for transfers.

Resident does not have two or more stage II decubitus ulcers at separate anatomic sites.

In order to meet HNF, the resident must meet LNF and meet a minimum of 2 High NF requirements.

LNF criteria is met as resident’s functional level is such that two or more ADLs cannot be accomplished without consistent, ongoing, daily provision or some or all of the following levels of services: skilled, intermediate and/or assistance

.

Slide49

Scenario 2

LNF vs.

HNF?

80 year old resident who has been a resident for 2

years as LNF and continues to need assistance with 2 ADLs.

Resident has slowly worsening dementia and heart failure.

Over the last 2 weeks, member has become increasing lethargic and short of breath with increasing edema.

Hospitalization suggested but family (POA) refuses. This is his home and they request treatment in NF, understanding risks.

Chest x-ray demonstrates worsening heart failure.

Physician

orders oxygen.

increased

diuretics; as well as vital signs, weight and O2 saturation checks daily and BMP

today

and in 3 days

time.

Further

orders are to contact MD with lab results  and make adjustments for

weight

change (up or down) of 3 + pounds and

sats

dropping below 90

%.

Nursing Facility requests 30 day HNF

Slide50

Scenario 2 - Results

Resident does

meet

HNF criteria.

The resident continues to meet LNF.

Resident meets HNF criteria by meeting 2 skilled needs:

OXYGEN    --------- daily skilled assessments

MEDICATIONS  --- daily

assessments

of VS &

weight &

lab reporting

If, after 30 days, the resident’s condition has stabilized, then the resident would resume approval as a LNF.

Slide51

Scenario 3

LNF

vs

HNF?

35 year old resident admitted 9 months ago

Requires no assistance with ADLs.

Medications stable per History and Physical and no adjustments in medications noted on Medication Administration record.

No changes noted in resident condition.

Documentation indicates member is homeless .

Diagnosis of Schizophrenia

.

Slide52

Scenario 3 - Results

LNF is not met as the resident’s functional level is not such that two or more ADLs cannot be accomplished without consistent, ongoing, daily provision or some or all of the following levels of service: skilled, intermediate and/or assistance.

Discharge Status criteria is met.

Slide53

Scenario 4

LNF

vs

HNF?

72 year old resident admitted 15 months ago

Admitting diagnosis – Alzheimer’s Disease with Behavioral Disturbances; member was being so disruptive at home that family could no longer provide care. In addition, member has hypertension and hypothyroidism

Medications include

Olanezepine

(

Zyprexa

), Levothyroxine, and

Metoprolol

. Medication is stable with no dose change for 4 months. The nursing facility progress note documents that the medicines have shown no side effects on an almost daily basis.

Member remains with disruptive behavior at times but is controlled with redirection by the aides. The Care Plan continues without significant

change

Slide54

Scenario 4 - Results

This member meets LNF criteria. Although the member is taking several medications that do carry “black box” warnings, the medication dosages have been stable without change. The member’s disruptive behavior, although still present, is stable, is handled by the nurse’s aides, and has not required any significantly new Care Planning process. Skilled intervention is not needed.

LNF criteria is met.

Slide55

FAQs

Nursing Facility Level of Care

Slide56

FAQs

Question 1: What information should I have to follow up on a submission?

Answer: You will need to provide:

Medicaid number, name and date of birth;

Your provider name;

The date the request was sent to

the Centennial Care

MCO

;

and

Item(s) or service(s) requested

.

Slide57

FAQs (Cont.)

Question 2:

What

information should I have ready when I call the Centennial Care MCO Member Services regarding status of a LOC request?

Answer:

You

will need to provide:

Resident Medicaid ID, name and date of birth

Your provider name and number or NPI

The date the request was sent

Service(s) requested

Question 3: How will I be notified when my request for LOC

has been completed?

Answer:

An

authorization or denial will be faxed back to you. If the request is approved, an authorization number will be provided with the approved level of care dates or Medicaid Pending dates

.

Slide58

Appendix

Nursing Facility Level of Care

Slide59

Appendix II - Forms

NFLOC Communication Form

NFLOC Notification Form

Slide60

Appendix III

PROGRAM POLICY MANUAL

ONLINE

http

://www.hsd.state.nm.us/mad/policymanual.html

Long Term Care Utilization Review Instructions for Nursing Facilities (8.312.2 NMAC)

Slide61

Thank you!