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 medically necessary level of care for long-term care placement based on nursing facility criteria. Level of care for nursing facility services is determined by Molina Healthcare TPA.
The initial request on form ISD 379 ("Long Term Care Assessment Abstract") must be accompanied by a valid physician's, nurse practitioner's or physician’s assistant order for the Medicaid level of care, the Level I PASRR screen or the PASRR waiver letter, a current history and physical (within six months of the assessment date for a new admission), and the clinical documentation to support eligibility for nursing facility placement.
New Requests for Persons Not Yet Enrolled in Coordination of Long-Term Services (CoLTS )
A valid level of care order must be signed, dated, and indicate the level of care requested (HNF or LNF). If the ISD 379 form is submitted for a resident whose financial eligibility has not yet been determined by the HSD Income Support Division, "Medicaid Pending" must be written across the top of the form by the nursing facility submitting the review packet. Upon notification of Medicaid eligibility, the facility must call Molina Healthcare TPA to inform the TPA of the effective date of Medicaid approval; days will then be applied to the abstract and a copy faxed to the facility.Continued stay requests
These requests must be received prior to the end of the current certification period. The nursing facility must provide a valid order for the level of care signed by physician, nurse practitioner or physician’s assistant 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
Molina Healthcare TPA 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 Molina Healthcare TPA unless there is a level of care change. Please refer to the Utilization Review Instructions for Nursing Facilities (Section 8.312.2UR) in the HSD/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 ISD 379 form, 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.