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The hospital is responsible for completing the FL-2 and sending it to the claims processing contractor for prior approval.
B. Decertified LTC Facility When a LTC facility fails to meet standards of patient care, the Centers for Medicare and Medicaid Services/Division of Health Service Regulation (DHSR) terminates the Medicaid certification. DHSR may also revoke the facility's license.
1. DHB sends a letter to:
a. The beneficiary’s representative; and
b. The a/b’s local agency of residence (county handling the Medicaid case).
2. The letter advises the following:
a. Medicaid will not pay for cost of care in that facility and the effective date.
b. The representative can request assistance from the local agency in locating another facility that accepts Medicaid.
c. That the patient may choose to remain in the facility beyond the Medicaid payment cut-off date; however, they are responsible for their cost of care.
3. If the beneficiary/representative chooses to remain in the facility past the Medicaid payment cut-off date, returns home, or enters an Adult Care Home, begin PLA budgeting the first day of the following month after timely notice is issued. (See XIII. below, for procedures.)
Timely notice requirements apply. Notice should be sent in time to affect the deductible the month following the last month of Medicaid payment.
4. After relocating to a new facility, update the facility code in NC FAST to ensure the DHB-5016's are sent to the new facility's address.
XI. CHANGE IN SITUATION This section explains how to handle ongoing Medicaid case maintenance when a change in situation is reported. The change could be a beneficiary move from PLA to LTC or LTC to PLA. If more than one change occurs in the same calendar month, evaluate the changes in the order they occur. A. Ongoing Beneficiary Becomes Institutionalized (Change From PLA To LTC) When a PLA beneficiary begins a CPI follow the procedures below to determine eligibility for cost of care. 1. Do a special review with the a/b or representative using the last DMA- Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493