Intermediate Care Facilities for the Mentally Retarded

Medicaid provides for medically necessary health services to eligible recipients in intermediate care facilities for the mentally retarded. Prior approval is required. 

For an initial review, the facility must submit form MAD 378 signed by a physician or with a physician's order attached. A history and physical current within one year, a psychological evaluation current within one year, and current valid assessments of functional development, behavioral, social, and health, and nutritional status. For a continuation of the initial approval, the facility must submit the completed MAD 378. Subsequent requests must include this information, as well as the most current quarterly nursing health status exam and a comprehensive functional assessment. 

 icon PDF Mad 378


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