CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Long Term Care Nursing Facility Checklist (NFLOC documentation and procedures)

Governs required documentation, submission timelines, and procedural steps for Nursing Facility Level of Care (NFLOC) requests, continued stays, LOC changes, transfers, re-admissions, Medicaid-pending requests, and discharge status for members in Blue Cross Blue Shield - New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLong Term Care Nursing Facility Checklist (NFLOC documentation and procedures)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a complete NFLOC packet with required forms and clinical documentation to the MCO to obtain an NFLOC determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 days30-day clinical recency

6 monthsPhysician order / H&P recency

12 monthsProgress notes recency (continued stay)

150 / 300Therapy minutes (1 / 2 HNF factors)

6Max no-auth hospital reserve days

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14 business daysTime for additional docs before denial

NFLOC Coverage and Documentation Criteria

inv-01: Documentation and submission criteria

Required documents by request type

ALL of the following

NFLOC Notification Form (Type = Initial Low NF or Initial High NF)
PASRR: Level I screen (prior to admission); Level II evaluation or PASRR waiver when Level I indicates SMI or ID/RC
Most recent complete Minimum Data Set (MDS) (completed per CMS schedule)
Physician's Order within 6 months specifying the Level of Care requested (signed by MD, CNP, PA, Clinical Nurse Specialist, RN, LPN who spoke with ordering practitioner; verbal/telephonic orders permitted)
History & Physical within 6 months (signed/dated by provider; if not signed must include date, name and credentials)

ALL of the following

NFLOC Notification Form (Type = Continued Stay Low NF or Continued Stay High NF)
Most recent complete Minimum Data Set (MDS) (completed per CMS schedule)
Physician's Order within 12 months specifying the Level of Care requested (signed as specified; verbal/telephonic orders permitted)
Progress Notes within 12 months (signed/dated by provider; if not signed must include date, name and credentials)

ALL of the following

NFLOC Notification Form (Type = Medicaid Pending-Initial or Medicaid Pending-Continued Stay)
PASRR: Level I screen; Level II evaluation or PASRR waiver when indicated
Most recent complete Minimum Data Set (MDS) (per CMS guidance/quarterly)
Physician's Order within 6 months specifying the Level of Care requested (signed as specified)
History & Physical within 6 months

ALL of the following

NFLOC Notification Form (Type = LOC Change)
Updated Physician's Order with effective LOC change date (signed as specified; verbal/telephonic orders permitted)
Clinical supporting documentation within 30 calendar days after the change in LOC

ALL of the following

NFLOC Notification Form (Type = NF Transfer)
Receiving NF must notify MCO within 30 calendar days of admission from another NF
Relinquishing NF to notify MCO of transfer and effective date

ALL of the following

NFLOC Notification Form (Type = Re-admission)
Hospital Discharge Summary
Resident Admission Note
Submit re-admit request within 30 days when applicable (e.g., after three hospital midnights)

ALL of the following

Care plan and interdisciplinary notes dated within 30 days
Oxygen: vitals with SpO2 documented
Behaviors: behavior grids and psych evaluations
Medications: MAR and medication orders
Rehabilitative therapy: therapy notes and minutes (therapy minutes totaled per week to determine HNF factors)
Skilled nursing: TAR, wound care and nursing notes

inv-02: NFLOC Required Documentation by Request Type

Required documents for various NFLOC request types (Re-admission, Discharge Status, Retrospective, Re-review, Reconsideration):

ALL of the following

NFLOC Notification Form (Type = Re-admission)
Hospital Discharge Summary
Resident Admission Note

ALL of the following

NFLOC Notification Form (Type = Discharge Status-Initial or Discharge Status-Continued Stay)
Documentation supporting attempted discharge planning

inv-03: Reserve Bed Days Policy

Reserve bed days and related prior approval requirements

ALL of the following

Up to 6 hospital reserve bed days per calendar year without prior approval
Up to 3 brief home visit reserve bed days per calendar year without prior approval

ALL of the following

Up to an additional 6 reserve bed days per calendar year available with prior approval
Prior authorization request must include: discharge plan with objectives; resident name and Medicaid number; requested approval dates; copy of the discharge plan; name and address of caregiver(s) during visit/placement; written physician order for trial placement

inv-04: Submission and Response Timelines

Timelines for submissions and responses

ALL of the following

Initial Stay: must be submitted within 30 calendar days after admission
Continued Stay: must be submitted 60 calendar days prior to current NFLOC expiration for LNF and 30 calendar days prior for HNF
Medicaid Pending: must be submitted less than 30 days from when the member is received on the ASPEN 112 file
Level of Care Changes: within 30 calendar days of change in LOC
NF Transfers: within 30 calendar days of change in facility

inv-05: Requests for Information

Requests for Information process and consequence

ALL of the following

MCO may issue a Request for Information when supporting documentation is missing or additional documentation is needed to complete a NFLOC determination
MCO will send a NFLOC Communication Form specifying requested information and will outreach to the Nursing Facility up to three times within a 14 business day period

Consequence if information not received: If requested information is not received by the 15th business day, the MCO will issue an Administrative Denial15 business days

Coding, Revenue & Therapy Thresholds

Neutral Codesmixed

LTC Custodial Care Revenue CodesRevenueCovered

0190	Low Nursing Facility Level of Care
0199	High Nursing Facility Level of Care
0182	Reserve Bed Days (Home Visit)
0185	Reserve Bed Days (Hospital Leave)

Therapy minutes per HNF factor

Therapy minutes per HNF factor150 minutes of combined PT/OT/ST per week = 1 HNF factor; 300 minutes per week = 2 HNF factors

Therapy compositionCan be any combination of Physical Therapy (PT), Occupational Therapy (OT), and/or Speech/Language Therapy (ST)

Measurement periodMinutes are totaled per week to determine HNF factors

Provider Submission Steps and Operational Actions

Prior Authorization

inv-09: Initial NFLOC Submission

Submit a complete NFLOC packet to the MCO indicating the request type as 'Initial Low NF' or 'Initial High NF' and include the NFLOC Notification Form, PASRR (Level I and Level II or waiver if applicable), the most recent complete MDS, a Physician's Order within six (6) months specifying the requested Level of Care, and a History & Physical within six (6) months.

NFLOC Notification Form — Type = 'Initial Low NF' or 'Initial High NF'
PASRR Level I (and Level II or PASRR waiver when applicable)
Most recent complete MDS (per CMS guidance)
Physician's Order within 6 months specifying LOC
History & Physical within 6 months

Documentation Required

inv-10: Continued Stay Submission

For Continued Stay requests submit the NFLOC Notification Form with the Type set to 'Continued Stay Low NF' or 'Continued Stay High NF' and include the most recent MDS, a Physician's Order specifying LOC dated within twelve (12) months, and progress notes within twelve (12) months.

Key Terms and Definitions

PASRR Level I/II

PASRR Level IA Level I Screen must be completed prior to admission on every nursing facility resident

PASRR Level IIIf Level I identifies a resident diagnosed with or suspected of Serious Mental Illness (SMI) or Intellectual Disability/Related Condition (ID/RC), a Level II Evaluation or PASRR waiver must be completed prior to admission

PASRR waiverA PASRR waiver may be used when applicable in place of a Level II Evaluation

Rehabilitative therapy thresholds

DefinitionRehabilitative therapy minutes are the combined weekly minutes of PT, OT, and/or ST used to determine HNF factors

Thresholds150 minutes/week = 1 HNF factor; 300 minutes/week = 2 HNF factors

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLong Term Care Nursing Facility Checklist (NFLOC documentation and procedures)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a complete NFLOC packet with required forms and clinical documentation to the MCO to obtain an NFLOC determination.

SourceLink

On This Page

Documentation explaining why resident must remain in NF or is at risk of discharging to community

ALL of the following

NFLOC Notification Form (Type = Retrospective)
Supportive documentation explaining the reason for delayed submission by the Nursing Facility
All other required documentation for the relevant request type (Initial, Continued Stay, Re-admission, LOC Change)

ALL of the following

NFLOC Notification Form (Type = Re-review)
Supportive documentation if applicable
All other required documentation for the relevant request type

ALL of the following

NFLOC Notification Form (Type = Reconsideration)
Supportive documentation (required)
All other required documentation for the relevant request type

MCO will provide a determination specifying authorized dates of service when prior approval is granted

Re-admissions: within 30 calendar days after hospital discharge

Discharge Status: within 30 calendar days of the NFLOC denial

ALL of the following

Request for Information: additional documentation must be submitted within 14 business days of the request
Re-review: must be submitted within 10 calendar days of the MCO's decision
Reconsideration: must be submitted within 30 calendar days of the Re-review decision
Appeals: must be submitted within 60 calendar days of the Notice of Action/Denial Decision

NFLOC Notification Form — Type = 'Continued Stay Low NF' or 'Continued Stay High NF'
Most recent complete MDS (per CMS guidance)
Physician's Order within 12 months specifying LOC
Progress Notes within 12 months

Denial Risk

inv-11: Medicaid Pending Submission and Timelines

When the MCO notifies the facility via the ASPEN 112 file for a Medicaid Pending case, the Nursing Facility must provide a complete NFLOC packet to the MCO within 30 calendar days of the MCO outreach or the MCO will issue an Administrative Denial.

MCO will contact the Nursing Facility upon receipt of ASPEN 112 notification
Complete NFLOC packet must be submitted less than 30 calendar days from MCO outreach
Failure to submit a complete packet per HSD requirements may result in an Administrative Denial

Documentation Required

inv-12: Level of Care Change

Submit a LOC Change request using the NFLOC Notification Form (Type = 'LOC Change') with an updated Physician's Order showing the effective LOC date and include clinical supporting documentation within 30 calendar days after the change.

NFLOC Notification Form — Type = 'LOC Change'
Physician's Order with updated LOC effective date
Clinical supporting documentation within 30 calendar days after LOC change

Documentation Required

inv-13: NF Transfer Notification

When a resident transfers from one nursing facility to another, the receiving facility must notify the MCO within 30 calendar days using the NFLOC Notification Form with Type = 'NF Transfer'; the relinquishing facility must also notify the MCO of the transfer and effective date.

Receiving NF: notify MCO within 30 calendar days (NFLOC Notification Form — Type = 'NF Transfer')
Relinquishing NF: notify MCO of transfer and effective date
If >30 days remain on prior authorization, MCO will fax the receiving NF the complete NFLOC form including prior authorization/bed days

Documentation Required

inv-14: Readmission Process

For readmissions after three hospital midnights, submit a re-admit MCO approval request within 30 calendar days and include the hospital discharge summary and the resident's admission note; follow alternate redetermination steps if less than 30 calendar days remain on the prior certification.

NFLOC Notification Form — Type = 'Re-admission'
Hospital Discharge Summary
Resident Admission Note
Submit re-admit request within 30 calendar days; if <30 days remain on certification, submit Redetermination instead

Prior Authorization

inv-15: Reserve Bed Days Prior Authorization

Request prior authorization for additional reserve/bed hold days beyond the automatic allowance; the prior approval request must include the resident's discharge plan, resident name and Medicaid number, requested dates, copy of the discharge plan, names/addresses of caregivers during the visit/placement, and a written physician order for trial placement.

Include objectives in discharge plan linking visits/placements to discharge implementation
Provide resident name and Medicaid number and requested approval dates
Attach copy of discharge plan and caregiver name/address for the visit/placement
Include a written physician order for trial placement

Denial Risk

inv-16: Requests for Information and Administrative Denial

If the MCO issues a Request for Information, the Nursing Facility must respond with the requested documentation; the MCO will attempt outreach three times within 14 business days and will issue an Administrative Denial on the 15th business day if information is not received.

MCO will send a NFLOC Communication Form specifying requested information
MCO will outreach three times within 14 business days
Administrative Denial will be issued by day 15 if information is not received

Documentation Required

inv-17: Re-review/Reconsideration/Appeal timelines

File a Re-review within ten (10) calendar days of the Notice of Action; if dissatisfied with the Re-review decision, submit a Reconsideration within thirty (30) calendar days of the Re-review determination; Appeals must be filed within sixty (60) calendar days of the Decision Letter.

Re-review: within 10 calendar days from Notice of Action (must precede Reconsideration)
Reconsideration: within 30 calendar days after Re-review determination
Appeal: within 60 calendar days after Decision Letter

Counting methodAll therapy disciplines are combined and totaled per week

Discharge Status

When requiredA Discharge Status review is required when the resident no longer meets NFLOC criteria for Nursing Facility placement

PurposeTo assess whether the member can be safely discharged or requires continued facility placement

Submission typesUse NFLOC Notification Form with Type = 'Discharge Status-Initial' or 'Discharge Status-Continued Stay' and include discharge planning documentation

Retrospective Review

TriggerRetrospective review is required when the Nursing Facility submits untimely reviews for Initial, Continued Stays, Re-admissions, or Level of Care Changes

Late submissionsMCO may assign unexcused late days if packet is submitted later than 30 calendar days from when due

MCO determinationMCO will decide if the late submission is excused or unexcused based on documentation provided by the facility