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2. ICF-MR level of care is intermediate care in a facility for the mentally retarded (ICF-MR).

3. Prior approval for treatment of head injury (HI level) care requires additional medical information not requested on the FL-2 form. The caseworker may be asked to request additional medical information.

B. Determination Of Level Of Care The Long Term Care Provider Manual (published by EDS) contains the medical criteria for levels of care. 1. The Long Term Care level (FL-2) is approved/disapproved by the Prior Approval Unit at EDS. The Mental Health Services level (MR-2) is approved or disapproved by the clinical staff at the Murdoch Center.

2. The county DSS must review the patient's Medicaid eligibility if the change is to a private living arrangement, including home or adult care home level of care.

Refer to the appropriate letter (figures) at the end of this section.

C. Prior Approval Process 1. The patient must have at least applied for Medicaid.

2. The FL-2/MR-2 may be initiated for completion by any one of the following people: the social worker at the county dss, the hospital discharge planner, the nursing facility, or the patient's attending physician. The Local Management Entity (LME) may also initiate the MR-2.

3. The FL-2/MR-2 should be completed by the patient's attending physician or licensed psychologist according to instructions on the back of the form. The MR-2 must also be signed by the LME representative. The PASARR must also be completed as required (See Table iii).

4. The patient’s attending physician or their designee should send all three copies of the completed FL-2 to EDS, Prior Approval Unit, P.O. Box 31188, Raleigh, NC 27622. The MR-2 should be sent to the Murdoch Center, Specialized Services, P.O. Box 3000, Butner, NC 27509. Include information below to assist in routing of the form or to resolve questions of the reviewer.

a. Name and mailing address of patient.

b. Name and address of patient’s representative if other than patient.

c. Name and telephone number of person completing the form.

d. Name and telephone number of contact person in county DSS, if available. Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493