Sandhills Center ICF-MR Provider Training

1. Sandhills Center ICF-MR Provider Training

2. ICF-MR Level of Care Initial Review • An ICF-MR Level of Care (prior approval assessment) is required for any individual under consideration for Sandhills Center ICF-MR Residential funding. • This assessment must be completed by the individual’s primary care physician prior to admission to an ICF-MR facility.

3. Individuals referred for ICF-MR funding will have their eligibility determined by a primary care physician. • Primary care physicians may complete the Medical Evaluation attachment to the Sandhills Center Level of Care Eligibility Determination Form, if needed.

4. The Medical Evaluation Form, if necessary and the Sandhills Center Level of Care Eligibility Determination Form are forwarded to the Sandhills Center Utilization Management Department (UM) for review. • The UM Care Manager reviews the information from the assessments and verifies that the documentation supports the eligibility criteria documented on the Level of Care Eligibility Determination Form.

5. If the assessments do not support that the person meets the ICF-MR Level of Care based on the review by the UM Care Manager, the Sandhills Center Medical Director will review the assessments and make the final determination. • The LOC Eligibility Determination Form is valid for 30 days from the signature date of the physician who completed the assessment and must be reviewed, approved or denied during that time period.

6. A unique number is assigned to LOC Eligibility Determination Form to document Prior Approval. Sandhills Center will determine the sequence of the numbers. • Sandhills Center retains a copy of the LOC Eligibility Determination Form, a copy is sent to DSS and a copy will be returned to the ICF-MR agency.

7. Utilization Review • Every 180 days Utilization Review (UR) will occur for individuals living in ICF-MR facilities. • ICF-MR agencies will be required to complete the Sandhills Center Eligibility Determination Form, and the Sandhills Center ICF-MR Utilization Review Request Form for each resident.

8. The Level of Care Eligibility Determination Form must be signed by the facility physician at the time of the scheduled UR. • Once completed the Level of Care Eligibility Determination Form (triplicate form) and the ICF-MR Utilization Review Request Form will be submitted to the Sandhills Center UM Department for review.

9. The UM Care Manager reviews the information on the LOC Eligibility Determination Form and verifies that it supports eligibility criteria. • If approved, the pink copy of the LOC Eligibility Determination Form will be return to the ICF-MR agency with the approval noted, the blue copy will be submitted to DSS, and the white copy will remain with Sandhills Center.

10. If the assessments do not support that the person meets ICF-MR level of care based on the review by the UM Care Manager, the Sandhills Center Medical Director will make the final determination.

11. Eligibility Forms • Level of Care Eligibility Determination Form • Medical Evaluation Form • To obtain Eligibility Forms call • Sandhills Center Call Center at • 1-800-256-2452 or Tena Campbell at 919-774-3786