Transcript Nursing Facility Level of Care

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
•
Nursing Facility Level of Care
DOCUMENTATION
REQUIREMENT
NFLOC Documentation
Requirements
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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)
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•
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
Physician Order Content
Requirements
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A valid physician order for NFLOC request must have the
following elements:
Signed by a physician, certified nurse practitioner, physician
assistant or clinical nurse specialist ; 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
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.
Readmission
The following procedure will be followed when a resident spends more than 3
midnights outside of the NF:
1.
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
2.
If resident is readmitted for LNF LOC certification, the NF needs to notify
the MCO of the readmission via fax using the Communication Form.
3.
If resident has less than thirty (30) days left on the NF LOC certification,
the NF should submit a NF LOC continued stay request.
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.
Discharge Status Documentation
Requirements

A valid LOC order
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Physician orders are valid for 60 days from date of receipt;
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ALL packets must include the MDS. Documentation must be
current for time frame requested;
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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
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The facility should document why the resident must remain in the
nursing home until the resident can be safely discharged to the
community.
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.
High Nursing Facility (HNF) Eligibility
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The resident’s functional level must first meet the
general eligibility requirements for LNF.
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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.
Nursing Facility Level of Care
HNF FACTORS
Factors for HNF: Oxygen
A.
OXYGEN
1. 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.
2. 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.
3. The resident is ventilator dependent, but otherwise medically stable per
documentation provided and the facility provides chronic ventilator
management capability.
Factors for HNF: Oxygen
B. Not Consistent with HNF
Resident requires supplemental oxygen which can be selfadministered. 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 noninstitutional setting.
The resident is ventilator dependent and has medical
needs which cannot safely be met at a nursing facility.
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.
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
•
Factors for HNF: Medication
Administration
A. Initiation (first 30 days) or adjustment of medications (7 days after
adjustment) in the following categories:
1. Anti-asthmatics/COPD: only during a respiratory exacerbation
2. Anti-infectives: only when given IV
3. Anti-hypertensives: only for med adjustments for systolic BP<=90 or >180/120
4. Analgesics: only when given parenteral
5. Antiarrhythmics
6. Anti-diabetic agents: only following hypoglycemic reactions requiring glucagon or
IV dextrose
7. Antipsychotics - daily monitoring by skilled staff for potential adverse reactions
and daily documentation of changes in problematic behavior.
8. 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.
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 prefilled syringes, can administer own subcutaneous or
intramuscular medications, and is cognitively capable of
reporting any adverse reactions to medications.
Medication dosing is stable.
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.
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.
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.
Factors for HNF: Skilled Nursing
A. Skilled Nursing
1.
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.
Factors for HNF: Skilled Nursing
Continued
2.
Wound Care
a. 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
b. 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
c. 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.
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.
Factors for HNF: Other Clinical
Factors
A. Other Clinical Factors
1. 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.
Factors for HNF: Other Clinical
Factors Continued
2.
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.
Factors for HNF: Other Clinical
Factors Continued
3.
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.
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
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.
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.
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The Centennial Care MCO will confirm Medicaid eligibility
by reviewing the daily enrollment data.
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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.
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If there is no current NF LOC certification, the Centennial
Care MCO will request the submission of documentations.
Nursing Facility Level of Care
LEVEL OF CARE REVIEWS
& LENGTH OF STAY
DETERMINATIONS
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.
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.
Modification of HNF LOC Requests
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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.
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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.
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A new LOC order specifying LNF LOC is not required on HNF to LNF
modified LOC approvals.
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LNF approval will be indicated on the authorization and will be faxed to
the nursing facility.
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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.
Workflow
Length of Stay Determinations
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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.
Length of Stay Determinations
Discharge Status
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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
Nursing Facility Level of Care
TRANSFER /
REINTEGRATION /
RECONSIDERATION
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.
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:
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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.
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A resident must have a 90 day nursing facility stay before an allocation will be given.
NFLOC Denials
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Technical Denial – there are no appeal
rights with a Technical Denial
Medical Denial
Reconsiderations
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.
Appeals
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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.
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.
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
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Nursing Facility Level of Care
SCENARIOS
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
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.
Scenario 2
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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
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.
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.
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.
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
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.
Nursing Facility Level of Care
FAQS
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;
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Your provider name;
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The date the request was sent to the Centennial Care MCO;
and
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Item(s) or service(s) requested.
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.
Nursing Facility Level of Care
APPENDIX
Appendix II - Forms

NFLOC Communication Form

NFLOC Notification Form
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)