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TABLE D -- When to Submit A FL-2, LOC or DHB-2193, Memorandum CAP Waiver Enrollment Status For Prior Approval

New Prior Approval Required [FL-2 with or without PASARR]

NOTE: Rehabilitation centers usually provide either SNF care, or the more specialized level of care, HI (head injury). Individuals who request Medicaid payment of cost of care in a nursing facility rehabilitation center are requested to have prior approval on the FL-2. If the care is HI, additional medical documentation will be submitted with the FL-2. TO From Hospital Nursing Facility ICF/IDD CAP/DA & CAP/C Innovations PRTF Home NO FL-2 w/PASARR LOC DHB-2193 LOC NO Hospital NO FL-2 w/PASARR LOC DHB-2193 LOC NO Nursing Facility NO FL-2 w/PASARR LOC DHB-2193 LOC NO ICF/IDD NO FL-2 w/PASARR LOC DHB-2193 LOC NO CAP/DA & CAP/C NO FL-2 w/PASARR LOC DHB-2193 is required if change in level of care LOC NO Innovations NO FL-2 w/PASARR LOC DHB-2193 NO NO PRTF NO FL-2 w/PASARR LOC DHB-2193 LOC NO Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493