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APPENDIX 100                                                                                               LEVEL OF CARE

NOTE:  If physician/ nurse practitioner indicates that client’s condition cannot be managed by provision of Community Care and/or Home Health Services, the physician may complete and sign a DMA-6


Care coordination team or the admitting/attending physician/ nurse practitioner certifies that client requires level of care provided by an intermediate care facility.


Admitting/attending physician certifies that CCP, plan of care addresses patient's needs for

Community Care.  If client’s needs cannot be addressed in CCSP and nursing facility placement is recommended, the physician may complete and sign a DMA-6.


This space is provided for signature of admitting/attending physician/ nurse practitioner indicating his certification that client needs can or cannot be met in a community setting.  Only a licensed physician (MD or DO) or nurse practitioner may sign the LOC page.

NOTE:  Physician/nurse practitioner signs within 60 days of care coordinator's completion of form.  Physician/nurse practitioner’s signature must be original.  Signature stamps are not acceptable.  UR will recover payments made to the provider if there is no physician/nurse practitioner’s signature.  “Faxed” copies of LOC page are acceptable.

38, 39, 40, 41, 42.      Enter admitting/attending physician's name, address, date of signature,

         licensure number, and telephone number, including area code, in spaces provided.                             

NOTE:  The date the physician signs the form is the service order for CCSP services to begin.  UR will recover money from the provider if date is not recorded.

43, 44, 45.       REGISTERED NURSE (RN) USE ONLY

43.    The registered nurse checks () the appropriate box regarding Nursing Facility Level

        of Care (LOC).  When RN denies a level of care, the nurse signs the form after the “No”

        item in this space.  The RN does not use the customized “Approved” or “Denied” stamp.

44.  LOS - Indicate time frame for certification, i.e., 3, 6, 12 months.  LOS cannot exceed 12

         months.   Certified Through Date - Enter the last day of the month in which the length of

         stay (LOS) expires.

45.     Licensed person certifying level of care signs in this space and indicates title (R.N.) and    

         date of signature.

         NOTE:  Date of signature must be within 60 days of date care coordinator completed

         assessment as indicated in Number 18.  Length of stay is calculated from date shown in

         Number 44.  The RN completes a recertification of a level of care prior to expiration of

         length of stay.  

        Distribution:  The original is filed in the case record.  Attach a copy with the CCC to DFCS

        at initial assessment and reassessment.  Include a copy with the provider referral packet.

MT 2010-1  8/09                                                                                        Appendix 100 page 78

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