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e. Patient's county of residence.

f. Patient's Medicaid ID number in block 5. The facility must contact DSS if the Medicaid ID number is not known.

g. Name and address of the patient's attending physician.

5. Incomplete FL-2 forms submitted to EDS will be returned to the county DSS and must be forwarded on to the attending physician with a request to complete and return as quickly as possible. The Murdoch Center faxes requests for incomplete information on the MR-2 form to the LME. The LME will then contact the appropriate person. 6. A new FL-2/MR-2 is required after 90 days, if Medicaid eligibility is lost or application is denied. 7. The approval process is complete when the stamped approvedFL-2/MR- 2 is returned from the fiscal contractor or the local management entity (LME) to the county. a. The approval date in block 13 of the FL-2/MR-2 will always be the date prior approval was given on the telephone or the date it was approved at EDS/Murdoch Center if the information was not telephoned to EDS/Murdoch Center. The effective date will be the same as the approval date unless a retroactive effective date is requested. b. If the admission date shows N/A, the effective date will be the same as the approval date. c. If the effective date is different from the approval date, it will be written in block 11 or 14 on the FL-2. It is usually written in by the person asking for prior approval and "highlighted". 8. If the facility or county realizes after receipt of the stamped approved FL- 2/MR- 2 from EDS/Murdoch Center that the approval date needs to be backed up to the date of admission, the facility must call EDS/Murdoch Center and give them the needed date. The caseworker should be alert to this possibility. 9. If the recommended level of care cannot be approved: a. The prior approval analyst will request additional information. b. If no response is received within 48 hours, a letter will be sent to the facility and the local agency indicating approval at the lower level of care.

D. Types of Prior Approval

1. Telephone/Fax a. Temporary FL-2/MR-2 prior approval may be obtained for patients Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493