Nursing Facilities: Prior Authorization, PASRR, and Level-of-Care Procedures
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Guidelines for managed care organizations (MCOs) and nursing facilities (NFs) on prior authorization, PASRR screening/evaluation, level-of-care (LOC) packet requirements, reserve bed days, lengths of stay, and related procedures affecting NF admissions and continued stays.
No material clinical or coverage changes in this revision.
Coverage and Level-of-Care (LOC) Criteria
inv-01: Nursing facility coverage and LOC criteria
Covered when the resident meets the nursing facility (NF) medical necessity and level-of-care (LOC) requirements; MCO LOC assignment and authorization timelines are specified below.
See submission and transmission timelines for completed packets.
ALL of the following
- Initial HNF approvals shall not exceed 30 calendar days (shorter stays may be assigned based on resident needs).
- Initial LNF approvals shall not exceed 90 calendar days (shorter stays may be assigned based on resident needs).
- HNF continued stay reviews may be certified up to 90 days based on medical needs and stability.
- LNF continued stay reviews may be certified up to 365 days based on medical needs and stability.
- Redetermination submission timing: medical documentation must be faxed and received by the MCO at least 60 calendar days prior to the new certification start date for LNF and 30 calendar days prior for HNF.
MCO will transmit the NF LOC determination via ASPEN within 24 hours of making the determination.
inv-02: Procedural criteria for NF LOC and related processes
Procedural rules and operational requirements that NFs and MCOs must follow for LOC requests, reviews, transfers, special statuses, audits, and appeals.
ALL of the following
- The NF must develop an individualized care plan for each resident within 48 hours of admission in accordance with 42 CFR 483.21.
- The care plan must include all specialized or rehabilitation services the NF will provide as a result of PASRR recommendations.
ALL of the following
- Maintain an emergency plan based on an ‘all-hazards’ risk assessment and update it at least annually.
- Implement policies and procedures addressing subsistence needs, evacuation, sheltering in place, and tracking during emergencies; review annually.
- Develop and maintain a communication plan that complies with federal/state laws and share emergency plan information with residents, families and the member's MCO.
- Provide training and testing, including annual drills and exercises to validate emergency procedures.
ALL of the following
- Written requests for prior approval based on retroactive financial eligibility must be reviewed by the MCO within 30 calendar days of the eligibility determination.
- The NF must submit all appropriate medical documentation for the NF LOC determination; the MCO will transmit the determination via ASPEN within 24 hours.
- Requests for retroactive eligibility will not be accepted after 180 days from the Medicaid eligibility determination date.
ALL of the following
- Medical documentation for initial, redetermination, re-admit and LOC change reviews may be reviewed retrospectively if requested by the NF.
- Unexcused late reviews: starting July 1, 2014, NFs may lose payment for each day the NF LOC review is submitted late.
- Excused late reviews: late submissions due to reasons beyond NF control must include a detailed written explanation and supporting documentation; reimbursement effective date depends on whether the delay was within NF control.
ALL of the following
- The receiving NF must notify the MCO by telephone of the transfer date; without notification, receiving NF claims will not be paid.
- If more than 30 calendar days remain on current authorization, the MCO will fax the receiving NF the completed notification form including prior authorization and dates.
- If less than 30 calendar days remain, the receiving NF shall request a continued stay on the notification form and the MCO will make a new NF LOC determination; write 'Transfer' in the type of request box.
ALL of the following
- All changes in LOC require submission of a new Notification Form within 30 calendar days of the change; mark the form 'LOC Change'.
- The NF must provide a signed and dated order from the physician, nurse practitioner or physician assistant and any documentation supporting the LOC request (see NF LOC Instructions and Criteria).
ALL of the following
- Discharge Status applies when a resident no longer meets NF LOC but cannot be placed in the community; it allows temporary continuation of coverage at LNF while discharge planning is pursued.
- Initial Discharge Status at LNF is authorized for up to 90 calendar days based on MCO physician determination; continued Discharge Status is authorized for not less than 180 and up to 365 calendar days with documentation of ongoing discharge planning efforts.
ALL of the following
- Providers may request re-review and reconsideration within specified timelines (e.g., re-review and reconsideration pathways); if member appeals an adverse determination and exhausts the MCO appeal process, an HSD administrative hearing is available.
ALL of the following
- MCOs and NFs must use approved HSD NF LOC Communication and Notification/Prior Authorization forms for all required submissions and communications.
- Notification and communication forms include fields for request types, documentation checklists, and required supporting documents.
ALL of the following
- HSD/designee will audit samples of MCO NF LOC determinations; each MCO must conduct quarterly internal random sample audits and report results to HSD by the 7th day following the quarter end.
inv-03: NF LOC documentation and UM review criteria
Required form fields, request types, and documentation items NFs must submit with NF LOC and prior-authorization requests.
ALL of the following
- Missing member demographics
- Missing MDS required fields or MDS not within requested service time frame
- Need a valid physician order specifying requested LOC
- Need PASRR Level I (and Level II if indicated) documentation
- Need current History & Physical (H&P)
- Need current signed and dated physician progress notes
- Medicare coordination of benefits information for dual-eligible members when therapy is used to satisfy HNF criteria
- Other supporting documentation as specified on the form
ALL of the following
- Minimum Data Set (MDS)
- Physician order signed and dated by an authorized clinician indicating LOC
- PASRR Level I and Level II if indicated (or PASRR waiver when applicable)
- History & Physical (H&P)
ALL of the following
- Most recent MDS
- Physician order
- Current physician progress notes
ALL of the following
- Date of review and authorization number
- NFLOC service begin and end dates and approved bed begin/end dates
- Approved clinical need items such as dressing, bathing, eating, transfer, mobility, toileting, oxygen, orientation/behavior, rehabilitation therapy, skilled nursing, medication administration, feeding, and other clinical factors to justify LOC
Documentation-linked Clinical Items and Code Lists
| No codes listed |
Provider Submission, Prior Authorization, and Appeals
Submit complete NF LOC packet (NF LOC Notification Form, MDS, signed dated order) within 30 days
All requests for prior authorization must be completed for each resident for every situation requiring prior approval and submitted to the resident's MCO by fax on the NF LOC Notification Form. The NF must include a completed MDS and appropriate supporting documentation with a signed and dated physician (or NP/CNS/PA) order indicating the requested LOC. The initial NF LOC packet must be submitted no later than 30 calendar days after admission. If required documentation is missing, the MCO will issue an RFI; failure to provide the information within 14 business days will result in a technical denial.
- Use the NF LOC Notification Form for all prior approval reviews and indicate request type (Initial, Continued Stay, Medicaid Pending, Transfer, Re-admit, Re-Review, Reconsideration, etc.).
- Include a completed MDS with all locator fields clearly marked.
- Include a valid order signed and dated by a physician, nurse practitioner, clinical nurse specialist, or physician assistant that indicates LOC (HNF or LNF).
- Submit initial NF LOC packet to MCO by fax within 30 calendar days of admission.
- Respond to any RFI within 14 business days or the packet will be technically denied.
Denial notice within 5 business days and MCO appeal pathway (Re-review → Reconsideration → appeal/hearing)
If NF LOC criteria are not met for initial placement or Medicaid pending, the MCO will send a denial letter to the referring party and applicant within five business days of receipt of a completed packet; providers may then request a Re-review and/or Reconsideration following timelines in section 6.15.
- Request a Re-review within 10 calendar days of the MCO decision notice (must be in writing).
- If dissatisfied with the Re-review, request Reconsideration in writing within 30 calendar days of the Re-review decision (subject to 'good cause' extensions).
- After exhausting MCO appeals, the member may request an HSD administrative hearing per applicable rules.
Late submission RFI process and potential technical denial (three contact attempts; ASPEN transmit)
If the NF submits the initial LOC packet later than 30 calendar days, the MCO may assign unexcused late days. When required documentation is missing, the MCO will issue an RFI and make three contact attempts during the 14-business-day RFI period; if no response, the MCO will transmit a technical denial via ASPEN within 24 hours.
- MCO makes three attempts to contact the NF during the 14-business-day RFI window.
- Technical denial is transmitted via the ASPEN interface within 24 hours of no response.
Submit notification/prior authorization for retroactive eligibility, re-admit, transfer, and LOC changes per timeframes
Submit prior authorization/notification forms to the MCO for retroactive eligibility, re-admit reviews, transfers, and LOC changes within the specified timeframes and include required supporting documentation; the MCO will transmit determinations via the ASPEN interface within 24 hours of making the NF LOC determination. Retroactive eligibility requests will not be accepted after 180 days from the Medicaid eligibility determination date.
- Retroactive eligibility requests: MCO reviews within 30 calendar days of eligibility determination; not accepted after 180 days.
- Re-admit reviews: submit within 30 calendar days with hospital discharge summary/admission note.
- Transfers: receiving NF must notify MCO by telephone of transfer date and submit appropriate notification form; write 'Transfer' in type of request box.
- LOC changes: submit new notification form within 30 calendar days with signed and dated order and supporting documentation; indicate 'LOC Change' on form.
Consequences for unexcused late submissions and requirements for excused late review requests
Unexcused late submissions may result in loss of payment for each late day; requests for excused late reviews must include a detailed written explanation and supporting documentation, and reimbursement effective dates depend on the cause of delay.
- If delay was within the NF's control, the reimbursement effective date is the date the packet was received by the MCO.
- Medicaid will not reimburse NFs for dates of service not covered by the MCO prior authorization form, and the NF may not bill the member or discharge the resident due to assignment of late days.
- Excused late review requests require submission of documentation showing reasons beyond the NF's control.
Request Re-review and Reconsideration then pursue MCO appeal / HSD administrative hearing if needed
Providers must follow the MCO's sequential appeal process: request a Re-review within 10 calendar days of the MCO decision, request Reconsideration within 30 calendar days of the Re-review decision (with possible 14-day extension for good cause), and, if adverse to the member, the member may file an MCO appeal and then request an HSD administrative hearing after exhausting MCO appeals.
- Re-review: written request to MCO within 10 calendar days; MCO returns decision within 6 business days.
- Reconsideration: written request within 30 calendar days of Re-review decision; MCO furnishes decision within 10 business days.
- If reconsideration decision is adverse, member may request an MCO appeal and subsequently an HSD administrative hearing after exhausting MCO appeals.
Complete NF LOC Notification/Prior Authorization Form and attach required documentation for initial and continued requests
When submitting an NF LOC prior authorization, populate the NF LOC Notification/Prior Authorization Form fields and attach required documentation: for initial requests include MDS, physician order, PASRR Level I and Level II if indicated, and History & Physical; for continuation include most recent MDS, physician order, and physician progress notes. The MCO's UM review will record review date, authorization number, NFLOC begin/end dates, approved bed dates, and approved clinical need items.
- Initial Request required items: MDS; Physician Order; PASRR Level I and Level II if indicated; History & Physical.
- Continuation Stay required items: Most recent MDS; Physician Order; Physician Progress Notes.
- UM review fields include Date of Review, Authorization Number, NFLOC Begin/End Date, Approved Bed Begin/End Date, and approved clinical need items (e.g., dressing, bathing, mobility, skilled nursing, rehabilitation therapy, medication administration).
Key Definitions and Forms
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