Nursing Facility
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.
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.
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.
