Page 2

2

(2) Under age 21, or

(3) Under age 22, and had 21st birthday while a patient in the state mental hospital.

d. Under age 21, or Psychiatric Residential Treatment Facility (PRTF) when the a/b is:

(1) Under age 21, or

(2) Under age 22 and had their 21st birthday while a patient in the psychiatric residential treatment facility.

e. General/Acute Care Hospital

OR

2. The a/b is admitted to a general/acute care hospital, psychiatric unit of a state mental hospital, or PRTF and their inpatient stay (of any length) ends with a direct move to one of the medical facilities listed in II.A.1.a. or 1.b. above,

OR

3. The a/b is admitted to a general/acute care hospital, psychiatric unit of a state mental hospital, or PRTF and their inpatient stay exceeds 30 continuous days, regardless of whether they go home or into an adult care home.

B. The a/b must have a completed FL-2/MR-2, if required, with at least telephone prior approval. The FL-2 may also be an electronic version and should be printed and put in the record. (See Table D) The local agency may accept telephone and fax verification of the prior approval from the facility. The caseworker must document who they spoke with, that person’s position, the facility they work with and the service review number (SRN).

The hospital social worker, local agency, medical facility representative, physician or Local Management Entity (LME) must initiate and complete an FL- 2/MR2. The FL-2 is forwarded to the Claims Processing Contractor Prior Approval Unit and the MR-2 is forwarded to the Murdoch Center for approval (refer to XV., below). The FL-2 is the Long-Term Care Services prior approval form and the MR-2 is the Mental Health Services prior approval form. It gives a summary of the patient's medical requirements. Medicaid will help to pay cost of care for an eligible individual with an approved FL- 2/MR-2. FL-2 is required for a swing bed.

FL-2/MR-2 is not applicable to psychiatric residential treatment facilities. PRTF services have a separate prior approval process. The county department of social services is not responsible for PRTF prior approval. Do not delay long term care budgeting for PRTF approval.

Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493